1 The Changing Behavioral Health Care Landscape: Integration, Innovation, and Financing Models Friday, May 17, 2013 County of San Bernardino Health Services.

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The Changing Behavioral Health Care Landscape: Integration, Innovation, and Financing Models

Friday, May 17, 2013County of San Bernardino Health Services Auditorium

Friday, July 12, 2013Koinonia Church, Hanford, CA

Friday, August 16, 2013San Leandro Marina Community Center

Friday, September 20, 2013Redding Memorial Veterans Hall

Charles G. RayAHP Healthcare Solutions

Thank You Sponsors!

• UCLA Integrated Substance Abuse Programs

• Pacific Southwest Addiction Technology Transfer Center

• California Department of Health Care Services

• County Alcohol and Drug Program Administrators Association of California

• NIDA Clinical Trials Network – Pacific Region Node and Western States Node

• Alameda County Behavioral Health Care Services

• County of San Bernardino Department of Behavioral Health

• Kings County Behavioral Health• Shasta County Health and Human Services Agency

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AGENDA

• Welcome & Introductions– Logistics and Orientation– Objectives

• Overview of Issues and Trends• Understanding Health Care Reform • Optimizing Behavioral Health Revenue• Innovations in Behavioral Health• Marketing Your Value-Add Propositions

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• Fear, anxiety and uncertainty are normal reactions to abnormal events

• These are abnormal times and abnormal events are unfolding around us with increasing frequency

• The Information Age, the Great Recession, Health Care Reform, elections, wars, and globalization represent a lot co-occurring abnormal conditions

• Complexity, volatility and paradigm-shifting ensue

Key Concepts

• This is your field. You worked hard to get here.

• This field was carved from the stone of ignorance and fear and discrimination

• We’ve won important Civil Rights battles in the form of the ADA, COBRA, HIPAA, EMTALA, MHPAEA and now the PPACA

• Our work is not done yet. Far from it!

• More to come for those who can perceive the opportunities and mobilize their resources despite the fear and uncertainty.

Key Concepts

• Discontinuity and Disruption (P. Druker)

• Instability (A. Toffler)

• Decay and Irrelevance (G. Hammel)

• Tipping Point (M. Gladwell)

• Strategic Inflection Point (A. Grove)

• Value Migration (A. Slywotzky)

• Disruptive Innovation (C. Christensen)

Key Concepts

Issues Reducing ED admissions and re-admissions

Medicaid managed care

Managed care business operations and infrastructure

Competition

Prescription drug abuse

Financial risk

Licensure and credentialing

Compliance with Mental Health Parity & Addiction Equity Act

State definitions of Essential Health Benefits

Preservation of system of care and prevention

Issues “Diabesity” epidemic

Whole health, person-centered care

Medication assisted treatment

Integration (vertical)

Consolidation (horizontal)

Carve-in

Retail healthcare

Health Coaches

Continued de-institutionalization

eHealth / mHealth

International Comparison of Spending on Health, 1980–20101

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Average spending on healthper capita ($US PPP)

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USNETHFRGERCANSWIZUKJPNAUS

Total health expenditures aspercent of GDP

Notes: PPP = purchasing power parity; GDP = gross domestic product.Source: Commonwealth Fund, based on OECD Health Data 2012.

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Health Care Costs Concentrated in Sick Few—Sickest 10 Percent Account for 65 Percent of Expenses

Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey.

Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 2009

1%5%

10%

50%

65%

22%

50%

97%

$90,061

$40,682

$26,767

$7,978

Annual mean expenditure

Problem: Causes of Premature Death in the General Population

N Engl J Med. 2007 Sep 20;357(12):1221-8.

30%

15%

5%

10%

40%

Proportional Contribution to Premature Death

Genetic dispositionSocial circumstancesEnvironmental ex-posureHealth careBehavioral patterns

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HEALTH CARE REFORMImpact Statement

Reform

1. Coverage expansion

2. New modelsa) ACOs and integrated delivery systemsb) Health Care (Medical) Homes & Dual Eligibles Initiatives

3. New administrative structurea) Essential Health Benefits (benchmark plans)b) Health Insurance Exchanges

4. New risk-based financing mechanismsMedicaid managed care and capitation

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Below 133% FPL ($29,500 family)

Medicaid Expansion To Childless Adults

• Coverage for essential MH/SA at parity for benchmark plan

• Feds pay 100% for 3 years, then down 90%

• Simplified enrollment, express apps: web too

• Integrated data with State exchanges: one application

• Foster kids up to age 26

133 – 400% FPL ($88,000 family)

State Exchanges

• Coverage for essential MH/SA at parity & prevention @ no co-pays

• Helps individuals and small employers with purchasing health insurance

• Assist by voucher to pay premiums or cost sharing

• Develops consumer friendly tools & plain language on insurance

• One application to both exchanges or Medicaid; can do on the web

Coverage Expansions

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California by the Numbers

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California by the Numbers

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California

California FQHCs

• 118 Federally-Qualified Health Centers Statewide

• 1,039 FQHC Service Sites

www.statehealthfacts.org

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Prevalence of Serious Mental Illness Among Adults Ages 18 – 64 by Current Medicaid Status and Eligibility for Medicaid Expansion

or Health Insurance Exchanges: California, US

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Prevalence of Substance Use Disorders Among Adults Ages 18 – 64 by Current Medicaid Status and Eligibility for Medicaid Expansion or Health Insurance Exchanges: California, US

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SUD in CA Medicaid Expansion and Health Insurance Marketplace

Most common characteristics of persons with SUD in Medicaid expansion population in California is:

• Male • 18-34 years old • Non-Hispanic White or Hispanic • Less than High School Education

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Sources: 2008 – 2010 National Survey on Drug Use and Health (Revised March 2012) 2010 American Community Survey

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California & ACOs• CMS has approved 400+ ACOs nationwide.• Include a range of providers and sizes; about half are

physician-led organizations that serve fewer than 10,000 beneficiaries.

• One-fifth include rural health centers, community health centers, and critical access hospitals, which serve rural and low-income communities.

• Nearly 30 ACOs in CA• Almost half sponsored by physicians and IPAs

(independent practice associations)

Sampling of Golden State ACOs1. Brown & Toland Physicians, based in San Francisco;

2. HealthCare Partners Medical Group, which serves Los Angeles and Orange counties;

3. Heritage California ACO, which serves southern, central and coastal California;

4. Monarch HealthCare, based in Orange County;

5. PrimeCare Medical Network, which serves Riverside and San Bernardino counties;

6. Sharp HealthCare System, based in San Diego

7. ApolloMed Accountable Care Organization in Glendale;

8. Golden Life Healthcare in Sacramento;

9. John Muir Physician Network in Walnut Creek;

10. Meridian Holdings in Hawthorne;

11. North Coast Medical ACO in Oceanside; and

12. Torrance Memorial Integrated Physicians

13. UCLA ACO

14. Cedars Sinai ACO

15. Hill Physicians/Dignity Health, serving Sacramento

16. Palo Alto Medical Foundation

17. Santa Clara County IPA

18. St. Joseph Health

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Golden State ACOs

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Golden State ACOs

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Golden State ACOs

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ACOs must develop a process for identifying patients who have complex needs (multiple chronic conditions) or are at high risk of developing such needs and provide them with wellness and prevention programs, disease management, and complex case management, as indicated

ACOs make available or support providers’ use of electronic prescribing, electronic health records systems, registries, and self-management tools

Population Health Management

Principles

Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

PCMH

Source: Patient Centered Primary Care Collaborative

Principles

Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services).

Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

PCMH

Source: Patient Centered Primary Care Collaborative

Quality and safety are hallmarks of the medical home:

1. Advocacy for patients

2. Evidence-based medicine and clinical decision-support tools guide decision making

3. Accountability for continuous quality improvement

4. Patients actively participate in decision-making and their feedback is sought

5. Health IT is utilized appropriately to support care, performance, education, and communication

6. Practices go through a voluntary recognition process

7. Patients and families participate in quality improvement activities at the practice level.

PCMH

Source: Patient Centered Primary Care Collaborative

Principles

Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication

Payment appropriately recognizes added value The payment structure should be based on the following framework:

• reflect the value of care management work and coordination of care

• support adoption and use of health IT and use of monitoring

• support enhanced communication such as secure e-mail and telephone

• allow share in savings from reduced hospitalizations

• It should allow for incentives for achieving quality improvements.

PCMH

Source: Patient Centered Primary Care Collaborative

Integration

Informing & Educating (patient and family education)

Measuring and Monitoring (testing, records, etc)

Assuring Access to Services (continuum of care, hotline, transport)

PreventionRisk FactorsScreeningMonitoring

AssessmentDiagnosis

HistoryTestingConsult

Preparing CounselingInterviewsTeaming

InterveningOrders

ProceduresCounselingTherapy

Recovery & Rehab

Fine tuningDischarge planning

Monitoring & Managing

ComplianceLifestyle

Feedback Loops

Managing Knowledge (training, process improvement, etc)

Provider Margins

made here

Patient Value defined here(health/cost)

Source: M. Porter and E. Olmstead Teisberg

Common Collaborative Care Models 1. Coordinated model: behavioral services available at a separate clinic/location

–Access and convenience is low; patients may not show up for referral/follow up care

2. Co-located model: behavioral services available at the same medical center/clinic

–More convenient for patients and providers

3. Integrated: behavioral services are part of the medical treatment within the clinic

–Creates a “medical home” for the patient with all services under unified management

–Facilitates closer communication, patient tracking and follow up

Source: Patient Centered Primary Care Collaborative

ACO PCMH

Characterized by sufficient structure, governance, and operations

Assure access and availability Focus on primary care and patient-

centered care Care Management and Navigators Clinical Pathways and EHR Patient Rights and Responsibilities Performance Reporting Shared savings

Personal physician-directed, whole person orientation

Care coordination and integration Facilitated by access to information Care Management and Navigation Quality and Safety focus Enabled by HIT/EHR Practice and financial management

ACOs and PCMH:Side-by-Side

What role do you see yourselves playing?

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ACO Payment

52.1

34.3

27.2

26.8

Percent of Hospitals' Payment Model

Shared SavingsShared Savings & Shared RiskGlobal PaymentPartial Capitation

Health Research & Educational Trust, 2012

Medicaid Expansion

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Medicaid Health Homes

• Defined in Section 2703 of the ACA–to expand traditional and existing medical home models–to build linkages to community and social supports–to enhance coordination of medical, behavioral, & long-term care

• New Medicaid State Plan Option effective 1/1/2011

- a comprehensive system of care coordination for individuals with chronic conditions • Health Home providers will coordinate all primary, acute,

behavioral health and long term services and supports to treat the “whole-person”

• Can include dual eligibles

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Health Homes

• The chronic conditions listed in statute include mental health condition, substance abuse disorder asthma, diabetes, heart disease, and obesity (as evidenced by a BMI of > 25).

• States may add other chronic conditions for approval by CMS

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Health Homes: Key Features

• Shared services, goals and risk

• Central management

• Community or regional networks

• Multi-disciplinary community health teams

• Dedicated care coordinators

• Integrated primary care/behavioral health services

• High-performing primary care providers

• Population management tools

• Health information technology & data exchange

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Health Homes: BH Rationale

• People with BH conditions die years earlier by up to 25-35 years

• One million people with behavioral health conditions will die from heart attack or stroke in the next 5 years.

• Behavioral health conditions are implicated in all major chronic diseases, and vice versa

• Disabled Medicaid beneficiaries with SMI - 29% to 49%. • SMIs represented in 3 of the top 5 most prevalent dyads

are in the highest-cost 5% of beneficiaries

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State Health Home ActivityAs of November 2012

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Medicaid Expansion

Between 2014 and 2019, a full Medicaid expansion will provide health insurance coverage to 17 million people with incomes less than 138 percent of the federal poverty level (FPL) who were previously uninsured.

About 40 percent of this group – or 6.6 million individuals – with serious or moderate mental illnesses who are currently uninsured will obtain health insurance through the Medicaid expansion by 2019.

Essential Health Benefits

Mental Health and Substance Use Disorders treatment are among what HHS calls Essential Health Benefits (EHB). States are defining these now.

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Parity & Equity AppliesThe Mental Health Parity & Equity Act (2008) applies to Medicaid Expansion, all Medicaid Managed Care Plans (expansion or not), and all CHIP.

Highlights

• Fair coinsurance (equal to majority medical co-pay)• Equitable access in terms of number days/visits allowed, frequency, duration of

treatment• Provides for in and out of network coverage where same is covered for medical• Mandates parity in utilization review guidelines and practices• Ensures access to and equitable coverage for inpatient, outpatient, ED and Rx

formulary • Disallows “EAP Gatekeeper” and “Fail First” practices in UM• Mandates fairness in network admission standards and method/setting UCR

rates of reimbursement for providers

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State ProgressAs of 1/4/13

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Who Benefits from the ACA?

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Community-Based Strategy forImproving Care of High-Cost Patients

Community governance

High-cost patients with multiple chronic

conditions

Payment reform Primary care Health information technology

• Medical home care management fee• Accountable Care Organizations• Bundled payment for acute episodes• Partial capitation• Shared savings and shared risks• Gain-sharing• Value-based purchasing• Public–private payer harmonization

• Medical homes• Primary care practice teams• System of off-hours care• Transitions in care• Reduced readmissions• Care coordination

• Electronic health records• Electronic prescribing• Meaningful use• Support for self-care• Mobile health applications• Computerized decision support

Regulatory relief, technical assistance

Seed funding

Synergistic Strategy: Cumulative Savings, 2013–2023

Payment reforms to accelerate delivery system innovation ($1,333 billion)

• Pay for value: provider payment incentives to improve care• Strengthen patient-centered primary care and support care teams• Bundle hospital payments to focus on total cost and outcomes

• Align payment incentives across public and private payers

Policies to expand and encourage high-value choices ($189 billion)

• Offer new Medicare Essential plan with integrated benefits through Medicare, offering positive incentives for use of high-value care and care systems

• Provide positive incentives to seek care from patient-centered medical homes, care teams, and accountable care networks (Medicare, Medicaid, private plans)

• Enhance clinical information to inform choice

System-wide actions to improve how health care markets function ($481 billion)

• Simplify and unify administrative policies and procedures

• Reform malpractice policy and link to payment*• Target total public and private payment (combined) to grow at rate no greater than GDP

per capita**

Source: Commonwealth Fund Notes: SGR = sustainable growth rate formula; GDP = gross domestic product.* Malpractice policy savings included with provider payment policies.** Target policy was not scored.

CONSOLIDATION & INTEGRATION

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M&A Activity 2012• In 2012, dealmakers committed $143.3 billion to finance

the year’s activity in the health care merger, acquisition and takeover market.

• In terms of the number of health care deals announced, 2012 was one of the busiest in the past decade, with 1,063 deals, up 5.9% compared with 2011’s 1,004.

Source: Irving Levin Associates, January 2013

Deals in 2012Sector 2012 2011 % Change 2012 Value 2011 Value % Change

Behavioral Care 17 13 30.8% $1,006,650,000 $304,488,600 230.6%

Home Health & Hospice 35 29 20.7% $5,718,950,000 $289,992,000 1872.1%

Hospitals 94 92 2.2% $1,886,217,010 $8,280,060,000 -77.2%

Labs, MRI & Dialysis 45 29 55.2% $2,213,817,500 $6,002,543,000 -63.1%

Long-Term Care 188 172 9.3% $9,180,208,579 $16,413,994,935 -44.1%

Managed Care 27 20 35.0% $18,815,500,000 $7,906,000,000 138.0%

Physician Medical Groups 68 108 -37.0% $4,411,539,350 $466,534,545 845.6%

Rehabilitation 18 14 28.6% $750,243,000 $1,337,796,000 -43.9%

Other 121 86 40.7% $12,033,703,400 $40,722,978,000 -70.4%

Services subtotal 613 563 8.9% $56,016,828,839 $81,724,387,080 -31.5%

Source: Irving Levin Associates, January 2013

Behavioral Health• This sector will see a lot more activity in the future, now

that mental health issues have gained national attention and addiction has lost much of its stigma

• Health care M&A activity will stay strong through 2013 as the sector looks forward to welcoming many more insured patients once the Affordable Care Act fully takes effect on January 1, 2014

Behavioral Health

• M&A activity in behavioral health has surged because in such a fragmented service sector, there is substantial untapped opportunity for consolidators to create critical mass and competitive advantages

• With acquisition demand across the spectrum of behavioral health and social services greater than supply, valuations have climbed.

Behavioral Health

Behavioral Health

Value of Behavioral Health

Source: Wyatt Matas, 2013

Value of Behavioral Health49% of Medicaid Beneficiaries with disabilities have a psychiatric illness. Top 3 behavioral dyads:

1. Psychiatric/Cardiovascular

2. Psychiatric/Central Nervous System

3. Psychiatric/ Pulmonary

Creating ValueMany providers will play a vital role in achieving value-based care milestones required by the ACA. Within these markets especially, value-based care requires:

1. Aligned leadership, 2. Strategies, and 3. Operations to align for the realization, building, or

maintenance of consistent growth

Source: Wyatt Matas, 2013

InnovationInnovation will be driven by Knowledge Networks and Markets (KNMs), largely made possible by health information technology to support decision-making for governments, systems, providers, and patients.

–Faster adoption of innovation. With key provisions and penalties in the ACA implemented in 2014, providers will scale to test and adopt innovative care models and population health approaches in 2013.

–Creative strategic alliances and alliance networks: bundled payments, ACOs and the lack of infrastructure to coordinate care across silos require providers to build formal strategic partnership alliances across healthcare: provider-to-provider, provider-to-vendor, and provider-to-payer relationships will accelerate in 2013.

Behavioral Health Value

• The market now understands the cost impact of patients with behavioral and physical health co-morbidities, leading payers to search, test, and develop new care models to address both behavioral and physical health.

• While integrating behavioral health and physical medicine, redefinitions of case management promotes need for cross-trained health workers, placing greater emphasis on social and life circumstances.

Factors Contributing to Growth

• National expenditures on mental health and substance abuse treatment are expected to reach $239 billion in 2014, up from $121 billion in 2003, representing a compound annual growth rate of nearly 7%.

• The demand for behavioral health services has increased in recent years due to earlier and more accurate diagnosis of mental health conditions and the de-stigmatization of seeking treatment.

Other Factors

• Influx of returning veterans from Iraq and Afghanistan

• Mental Health Parity and Addiction Equity Act• Affordable Care Act• Essential Health Benefits• Medicaid Expansion• Diverse Payer Mix• Niche markets and segments

BUILDING NEW BUSINESS & NEW REVENUE STREAMS

Vision, Goals, Objectives

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Marketing Basics1. Is there a market for what you have to sell? What specifically is that

market?

2. What particular product(s) are in highest demand?

3. What level of competition exists in each space?

4. What regulations and other constraints act on those products and

markets? How?

5. What does it cost to produce your product or service?

6. What price is acceptable to each market?

7. Are the margins sufficient to become successful and maintain

viability?

8. Is it possible to innovate your product making it more effective, less

complex and more convenient for the consumer at a lower cost?

Market Data Analysis

What does market profile data tell you about:a. Competition among payers?b. Competition between key providers?c. Availability of continuum of services?d. Gaps in services, populations served, or holes in

service areas?e. Opportunities to innovate?f. Opportunities to provide payers with a real

solution to a real problem? g. Opportunities to partner?

Soft Market Research

Visit and scour payer websites Read their provider newsletters Ask the Insurance Commissioner/Department for any

and all information specific to a particular payer Identify their Board members Call and speak with Provider Relations Talk to your agent/broker Download and study provider manuals, practice

guidelines, provider network directories, and applications

What Constitutes Market Research for Behavioral Health Providers?

• Population/Census Data• Prevalence and Epidemiological Data• Competitive Analysis• Health Insurance Market Research• Analysis of Medicaid Market• Due Diligence into Potential Partners• Laws, Rules and Regulations• Reimbursement • Other?

PRODUCT & SERVICE-LINE INNOVATION

5 Reasons to Innovate Now

1. Advent of health care reforms

2. Cycle of breakthrough in research and brain science

3. Prevalence of psychiatric and substance use disorders and incidence of trauma among Veterans and children

4. Explosion of diabetes, asthma, autism, and obesity

5. Availability of consumer and provider-friendly technologies

What Drives

Innovation?

Customer Needs & Market

Demands

Access to Capital

Access to Technology

Market Structure

Ancillary Markets

Skills and

Abilities

R & D

Elements of Disruptive Innovation

Technology simplifies what had previously been complicated and cumbersome

Lower-cost financial model

Value Network is economically coherent (mutually reinforcing)

Source: Clayton Christensen

Why Innovate?

Innovation for sake of novelty

Innovation for sake of change

Innovation to gain strategic advantage over competition

Conditions Is the political, legislative and regulatory environment

stimulating change in the market (YES!)

Is government supporting the diffusion of innovations (YES!)

Has the economy performed at a level that is impacting consumer behavior and pricing? (YES!)

Are social and cultural dimensions of the market supportive of new approaches? (YES!)

Is technology supporting innovations? (YES!)

Innovation FrameworkResearch – better understanding the market, unmet demand, customers and their preferences, pricing and profit models, the cutting-edge of science and technology, and value networks across partners and supply chain.

Review existing product-line and previous attempts at innovations Survey payers, customers, partners, line-staff and leadership team Analyze customer pain points Assign Innovation Instigators across the ranks Conduct key informant interviews Conduct environmental scan and literature review Conduct market research and competitive intelligence Review financials and other business intelligence

Innovation Framework

Development – identifying a more effective and efficient way to promote and manage disruptive innovations, pilot programs, demonstrate viability and bring new products to market

Product Development and Innovation Process Learning to ask disruptive questions Looking for natural product bundling opportunities Observing how customers interact with services today to detect

opportunities for improvement Investigating and experimenting with new ways of doing things Networking and associating with people, technologies, and ideas

from diverse backgrounds

Innovation Framework

Identifying: Gaps, voids and opportunities Market compatibility Quality and compliance standards Key performance indicators, forecasts and projections Potential issues and risks Early-stage business operating and/or financial models and

their implications

Innovation Framework

Critiquing the proposal Is the proposal overly optimistic or too cautious? Is quality assured? Were there contrary opinions on the Team? Are there credible alternatives to the proposed solution? Is there sufficient data to support the decision? Valid sources? Is there an assumption of success with the pilot based on past

performance elsewhere? Where? Is planning overconfident? Is the worst case awful enough?

Innovation FrameworkPrototype and Pilot Develop the product/service in its entirety, ready to test

Execution – planning and deploying new products with adequate resources and management, reporting progress, remaining accountable, capturing lessons-learned, and knowing when and how to say “No”

Develop proof of concept model and parameters Decide whether to pilot prototype internally, to out-source it, or to spin it off under its own brand Implement the strategy, develop and test the product/service Manage expectations, people and outcomes

Innovation Framework

Evaluation – measuring the impact of the new product and the success of the implementation team

Actual costs, revenues, and profits Return-on-Investment Customer, Employee and Payer Satisfaction Customer Experience Quality Outcomes Market demand

Opportunities for Innovation

Multiple Chronic Conditions (MCC) Clinical Pathways Care Coordination Health Informatics

Health & Wellness

Prescription Drug Monitoring Programs and Pain Mgmt.

Population Mgmt.

New market structures: Accountable Care Organizations (ACO), Patient-Centered Medical Home and Health Home Models (PCMH) – Focus on Primary Care Integration

TELE-HEALTH

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Tele-Health

Two types of Tele-Health

1. Live interaction

2. Store and Forward

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Quick Facts about Tele-Health in CA

AB 415 replaces the terminology of “telemedicine” with “telehealth” in California law.• Under the old law’s terminology, telemedicine was defined as the practice

of medicine via live video connections between patients and providers in separate locations, or via “data communications.” Telehealth is broader.

• AB 415 was an update to the Telemedicine Act of 1996. It allows for the provision of a broader range of telehealth services, expansion of teleheatlh providers to include all licensed healthcare professionals, and the expansion of telehealth care settings.

• AB 415 does not mandate the use or reimbursement of any telehealth services by public or private payers. Covered services, and the locations of their delivery, are still negotiated in contracts between health plans and providers, and in public insurance programs such as Medi-Cal, the state’s Medicaid program. Nor does AB 415 change the scope of practice of any licensed health professional, or change interstate licensure laws.

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Quick Facts about Tele-Health in CA

AB 415 removes limits on the physical locations where telehealth delivered services may be provided.• Under the old State law, Medi-Cal restricted delivery and receipt of

telemedicine services to four specific licensed facilities: hospitals, clinics, doctors’ offices, and skilled nursing facilities.

• AB 415 clears up the confusion on location by explicitly removing limits on the settings for telehealth. This will allow for services delivered via telehealth to be covered, regardless of where it takes place.

• However, locations for telehealth are still subject to policies and contracts enacted by Medi-Cal and private payers.

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Quick Facts about Tele-Health in CAAB 415 expands the definition of health care provider, to include all health care professionals licensed by the State of California. Under the old law, only these health professionals could provide services via telehealth:• Physicians• Surgeons• Podiatrists• Clinical psychologists

AB 415 expands this list to include all professionals licensed under the state’s healing arts statute, which also include:• Pharmacists• Nurse practitioners• Physician assistants• Registered nurses• Dental hygienists• Physical therapists• Occupational therapists• Marriage, family and child counselors• Dentists• Optometrists (in limited scope)• Speech and language pathologists• Audiologists• Licensed vocational nurses• Psychologists• Osteopaths• Naturopaths

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Quick Facts about Tele-Health in CA

Additional Resources

CCHP

Established in 2008 by the California HealthCare Foundation, the Center for Connected Health Policy (CCHP) is a non-profit planning and strategy organization working to remove policy barriers that prevent the integration of telehealth technologies into California’s health care system. CCHP conducts objective policy analysis and research, develops non-partisan policy recommendations, and manages innovative telehealth demonstration projects.

www.connectedhealthca.org

CTEC

CTEC is one of the country’s leading resources for telehealth education, expertise, and implementation guidance. A federally designated Telehealth Resource Center, CTEC is the go-to source for unbiased information, serving healthcare providers, health systems, clinics and government agencies. Working to make telehealth services widely available, CTEC creates systems that make people healthier, increase access to care, improve patient outcomes, drive down healthcare costs, and sustain a reduced-carbon economy. For more information on CTEC, please visit www.cteconline.org

Medi-Cal Telemedicine Guidelines http://files.medi-cal.ca.gov/pubsdoco/DocFrame.asp?wURL=publications%2Fmasters-mtp%2Fpart2%2Fmednetele_m01o03.doc

Funding Tele-Health

FCC Healthcare Connect FundCTN Will Begin Enrollment in April 2013

As California’s authorized FCC broadband consortia for healthcare, the California Tele-Health Network (CTN) has priority access to the Healthcare Connect fund for California health care providers and will begin enrolling providers in the program as soon as April, 2013. In addition, for most CTN members the 35% match requirement will be reduced by half. The FCC award funds will pick up the remaining cost of infrastructure development.

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BEHAVIORAL MEDICINE

Issues of BH in Primary Care

The importance of primary care integration–PCPs deliver half of BH care–PCPs prescribe 70% of psychotropic drugs–PCPs have limited BH training; widespread under diagnosis

–Up to 70% of primary care visits stem from psychosocial issues

Problems faced by PCPs–PCPs have limited time to treat psychosocial issues–BH care inaccessible to PCPs–Many referrals do not result in visits/services

Behavioral Medicine

“the field concerned with the development of behavioral science knowledge and techniques relevant to the understanding of physical health and illness and the application of this knowledge and techniques to prevention, diagnosis, treatment, and rehabilitation”

Yale Conference on Behavioral Medicine

Behavioral Medicine Targets

Cystic FibrosisDepressionDiabetesEating Disorders HIV/AIDS Obesity Pulmonary Disease Substance Use Disorders

including Smoking Cessation

Women's Health

Adolescent HealthAgingArthritisAsthmaCancerCardiovascular Disease

(heart disease, hypertension, stroke),

Children's HealthChronic Pain

Behavioral Medicine

Strategies Integrating behavioral medicine strategies into primary

care and managed care; Increasing public awareness of behavioral interventions; Including effective behavioral interventions in development

of clinical practice guidelines; Increasing use of information technology for behavioral

interventions; Improving integration of research and practice

Psychiatric Outpatient Outpatient MH

CounselingSUD Outpatient

ResidentialPsychiatric Inpatient

Emergency Department Pediatrics, Childhood

Trauma, SED

Heart Disease - Cardiology

ID/DD, Autism

Diabetes and Obesity

COPD, Asthma, Tobacco Use

Prescription Drug Mgmt., Drug-Seeking, Narcotic Medication Abuse (pain meds, sleep meds, anxiety meds), Pharmacy Consult/Education

SBIRT

Health Home, Health Neighborhood, PCMH, ACO, CCO

Intensive Case Mgmt, Care Coordination, ACT

Disease Mgmt

Get the Big Picture

How Many Opportunities for Innovation Might There Be?

95

Behavioral Medicine

A. Doesn’t seem to be very important

B. Is not something we can afford to wade into this year

C. Requires more expertise than we have available

D. Is something we are already engaging in quite well

E. Is something we are totally committed to doing as soon as feasible but we need additional resources

Doesn

’t se

em to be ve

ry...

Is not s

omething w

e can...

Requires m

ore exp

ertise

...

Is so

mething w

e are alr..

.

Is so

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New Mind-Set“We don’t serve the indigent. We treat people.”

“What were once our “consumers” have become our patients. Consumers consume. Patients are treated by healthcare professionals.”

“Our facilities should be as dignified and comfortable as any business that hosts and serves people.”

“We are a vital and integral facet of the healthcare delivery system.”

“The people we serve are not “non-compliant” and they don’t “drop-out”. They don’t have “dirty” UAs. They have a chronic disease that is highly treatable.”

“We do everything we can to partner with or recruit MDs and NPs”

“We provide sub-acute inpatient treatment services”

MARKETING PLANSGetting into Action

97

Fundamentals of Market Positioning

• Market Research• Customer Value Proposition• Channels, Alliances and Partnerships• Product Development• Pricing• Brand Message Our job is to find the gaps that exist in

the system of care and in the market.

Who would pay for what given the opportunity?

• Market segment traits and features• Promotion mix to reach segment(s) • Detailed approach and methods• Timeline, milestones, tasks• Key performance indicators• Organizational chart and supervision• Resource needs• Budget

Marketing Action Plan

Business Models and Customer Value Propositions

Answers the Essential Question:

“Why should I buy from you instead of buying what your competitor has to offer?”

CVP is NOT1. Your services2. A list of benefits

and features3. Your Mission4. Your tagline5. A headline

101

Customer Value Propositions (CVP) address customers’ perceived value and attempt to position services such that the value returned to the customer is greater than perceived cost.

However, as in the case of brand truth, there is true value to keep in mind. If you promise an experience of value and fail to deliver…

What is a Customer Value Proposition?

Patient CVP

What are their needs?• Effective treatment for their behavioral health

issues• Support for/from their families and community• Safe environment• Convenience• Lack (or reduction) of stigma• Re-entry plan (for residential programs)• Post-treatment support• Financial issues addressed

Referral Source CVPWhat are their needs?

• Effective treatment• Access and convenience of easy referral process• Treatment options and in-network status • Communication and collaboration• Confidence• Timely reporting and reliable follow-up• Lack of resistance and/or negative feedback from

clients• Gratitude • Reciprocal referrals

Payor CVP

What are their needs?• Evidence based practices that produce better

outcomes at lower cost• Access to adequate specialty provider network

coverage• Positive patient experience and member

satisfaction ratings to meet performance incentives• Low risk and low exposure to fraud, waste,

malpractice• Shared interest in making best use of finite

resources, particularly for chronic conditions

Differentiators

• Populations Served• Continuum• Quality • Access (location, after-hours, weekends)• Health and QoL Outcomes• Alumni Program• Outreach• Privacy and Security• Education, Job Training, Transportation, Child

Care

Communicating your Customer Value Proposition

• Your organization's name

• Your graphic identity and slogan

• Your signage

• Your web site

• The names of your services/programs

• Your collateral materials (e.g., brochures, staff bios)

• Letters and telephone calls

• Talking points for your staff and stakeholders

• Ads, videos, blogs, social media…

Exercise Customer Value Proposition

Customer Segment Job to be Done Pain (avoid) Gain (deliver)

Patient and/or family

Payor – private insurer and/or managed care organization

Employer

Referral Source – health care/medical/MH and/or hospital

Referral Source – CJ

Referral Source – EAP and/or Case Mgr

Referral Source - Interventionist

State/County agency

Exercise Customer Value Proposition

Key Question Your Answer

Our intended customer is…

They will find us (where)…

What we do together in exchange is…

They chose us because…

Exercise Customer Value Proposition

Key Question Answer How do you know? Resonates with? Who cares?

Compared to the Next Best Alternative, we…

Quality

Access

Price

Outcomes

Quality of Life

Other

110

Business Model Canvass

Key Partnerships

Customer Segments

Value Proposition

Key Activities

Key Resources

Customer Relationships

Channels

Cost Structures Revenue Opportunities

Opportunity: Assessment

• Assess Board, leadership team and staffing• Evaluate market share and contracts, partnerships and alliances• Assess finances, reserves and revenue cycle• Evaluate IT Infrastructure (practice management, billing, EHR) • Develop new business processes, quality programs and other

performance measures

Build: Managed Care Competencies Contemporary Brand

• Board comprehension and support for reforms• Performance measures• Staff credentials• Reserves• IT• Business partners, shared services and networks• Marketing action plans

Challenges

• Strategic plans (6 months and older)• Leverage negotiating contracts and understanding of

terms and conditions• Revenue cycle management• Outcomes and Quality measures in new markets• Managed care competencies• Facilities and brand image

Challenges

• ACOs and CCOs• Self-Insured Plans (ERISA)• Traditional Indemnity (fully-insured)• Managed Care Plans

–MBHOs (carve-out)–HMOs (network-centric, referral-based)–PPOs (wider network, medical necessity standards)–POS (combines HMO and PPO with coinsurance differentials)

Assessing the Market

• Relationship to Insurance Commissioner• Familiarity with association of health plans and

underwriters, HR and benefits associations• “Getting In” - commercial marketing and

contracting • Reaching veterans

Challenges

• Federal, State and county budgets

• State laws and regulations

• Scope of service and scope of practice

• Waivers and State Plan Amendments

• Health Insurance Exchange

• Reimbursement reforms and other funding opportunities

• Mergers and Acquisitions, joint ventures in local health care sector

Assessing the Environment

• Defining scope of service and scope of practice• Definition of Essential Health Benefits• Question of Medicaid Expansion• Reimbursement reforms and financial risk• M&A due diligence and alignment of vision, mission,

cultures and values

Challenges

• Time• Expertise• Capital required to develop effective, manageable

plans• Competing priorities• Tension between “the way we’ve always done it” and

the paradigm shift

Challenges

Market Planning

• Define and Segment the Market• Identify New Prospects• Identify Emerging Needs• Product Development / Innovation• Develop Unique Selling Proposition (USP) and

Customer Value Proposition• Packaging (promotional materials), Promotion and

Placement (billboards, media spots, press)• Competitive Analysis and Intelligence

• Managed approach to plan execution• Meaningful differentiation• Habit of being too under-resourced to promote business

interests• Treatment philosophy versus business strategy

Challenges

Next Steps: Strategy• Become a Learning Organization…Now

– Reforms and regulations– Markets and trends

• Think Innovation– Simpler, enabled, less costly– Adds value

• Lead– Champion the strategy

• Hold Everyone Accountable for Results– Do what matter most

Next Steps: Strategy• Build from your Core and Craft a Value Proposition

– Focus on patient experience and quality– Show “value creation” capabilities

• Assure Infrastructure is Ready– IT, staff, workflow, and Evidence-Based Practices

• Build Alliances– Networks and new business relationships (MH, hospitals, ACOs,

FQHCs and primary care)

• Make your Presence Known– Assert evidence that you must be a partner

• Your vision, your mission and your customers• Your commitment to your field, your employees and

their families• The needs of your communities• Your Board’s understanding and participation• Your bottom-line, sustainability and viability

Challenge: Remember…

Thank You! Questions

Angela Halvorson

[email protected]

217-553-2633