Health Care Reform: What is it? Why are we doing it? How will it affect psychiatry? Wisconsin Psychiatric Association Annual Meeting December 2014 Robert.

Health Care Reform:What is it? Why are we doing

it?How will it affect psychiatry?

Wisconsin Psychiatric Association Annual MeetingDecember 2014

Robert N. Golden, MDDean, School of Medicine and Public Health

Vice Chancellor for Medical AffairsRobert Turell Professor in Medical Leadership

Professor of PsychiatryUniversity of Wisconsin-Madison

US Health Care “Brain Trust”

What is Health Care Reform?

• Morality – Poor people without insurance receive substandard care and suffer or die unnecessarily

• Efficiency – Greater percentage of GDP spent on health care with worse outcomes

• Fiscal Sustainability – Health care costs rising faster than real GDP growth

Health Care Reform: Why?

CMS, April 2010

Health Care Reform

• Morality – Poor people without insurance receive substandard care and suffer or die unnecessarily

• Efficiency – Greater percentage of GDP spent on health care with worse outcomes

• Fiscal Sustainability – Health care costs rising faster than real GDP growth

Health Care Reform: Why?

Total Health Expenditures asProportion of GDP – 2009

• Morality – Poor people without insurance receive substandard care and suffer or die unnecessarily

• Efficiency – Greater percentage of GDP spent on health care with worse outcomes

• Fiscal Sustainability – Health care costs rising faster than real GDP growth

Health Care Reform: Why?

Big future deficits projected by Congressional Budget Office are largely a result of growth in health care spending and, to a lesser extent, in Social Security. Projections assume that other forms of spending will shrink as a share of GDP.

Sources: Congressional Budget Office; Center on Budget and Policy Priorities

Growth of Federal Spending

The Wedges of Waste

Berwick, JAMA 2012307(14) 1513-1516

• A transition to outcomes-focused reimbursement

• Operating efficiency will replace

revenue growth as driver of profitability

• Total cost management will supplant fee-for-service incentives in the health system business model

Actualization of the Triple Aim

• Rewards in clinical practice will focus on coordination, chronic disease management, and population health

• Bundled payments and other reimbursement innovations will make specialty care more rare and less profitable

• Information-driven care, not simply information technology adoption, will become a competitive differentiator

Actualization of the Triple Aim

• As of January 1, 2014, all U.S. residents are required to maintain minimum essential coverage unless the individual falls into an exemption

• Individuals are required to maintain essential coverage each month or pay a penalty

• Penalty equals greater of flat dollar amount or percentage of individual’s income:

$95 in 2014 or 1% of taxable income $325 in 2015 or 2% of taxable income $695 in 2016 or 2.5% of taxable income

Individual Coverage Mandate

• Non-grandfathered, individual and small group plans, inside and outside of the new Health Insurance Marketplace, must cover a core package of items and services, known as Essential Health Benefits

Result: These standards help consumers become more confident

when comparingand selecting health plans

Essential Health Benefits

• Ambulatory Care• Emergency Care• Hospitalization• Lab Services• Maternity and Newborn Care• Mental Health and Substance Abuse• Pediatric Services (Oral and Vision)• Prescription Drugs• Rehabilitative and Habilitative

Services• Wellness and Disease Management

Essential Health Benefits

Are We Built for the Job?

• “The effectiveness of ACOs willdepend on the centralization of the administration of medical care, whereas clinical departments in medical schools operate on a decentralized model.”

- Kastor, NEJM, 2/2/2011

Preferred Health Plan Features

Preferred Health Plan Features

Insurance Reform Delivery Reform

IntegratedCare

BetterCoverage

QualityFocus

MorePeople Innovation

MedicaidExpansion

Exchanges

GuaranteedIssue

PreventionBenefits

Cost: MLR,Rate Review,M’Care Adv.

CareTransitions

Dual Eligibles

ACOs,Bundles

PrescriptionDrugs

PreventionFunds

Fraud andAbuse

Transparency,Data Sharing

Value-BasedPayment

CMMI

PricingReforms

FQHCsKids < 26

Don Berwick, GPIN, Boston, MA, Oct. 17, 2012

(Partial) Structure of ACA

Delivery/Payment Reform: Goal

“Improve Medicare beneficiary health outcomes and experience of care by using payment incentives and transparency to encourage higher quality, more efficient professional services.”

--> Value = Quality/Cost U.S. Department of Health & Human Services. Development of a Plan to Transition to a Medicare Value-Based Purchasing Program for Physician and Other Professional Services. Issues Paper [accessed 15 Nov 2012] http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/PhysicianVBP-Plan-Issues-Paper.pdf

Tertiary/Quaternary Care

Secondary Care

Primary Care

Market Segments

Bundles

Population H

ealth

Management

Strategy: Bundled Care & Payment

Diagnostic Services

Procedure

Outpatient Follow-up

$

Diagnostic

Services

Procedure

Outpatient

Follow-up

$

$$

$

$

$

$

$

$

Bundled Care & Payments: Care processes provided and paid for as a bundle; Promotes coordination, quality & efficiency

Fee for Service: Care processes provided and paid for independently; Promotes silos and more services

Delivery System & Payment Reform

• Movement is toward paying for Value– Highest quality care at the lowest

cost

• Increasingly, providers will be assuming financial risk for the care of different sets of populations

• Learn to think about (and manage) populations and episodes of care

Impact on Health Insurers

Macro Impacts on Health Insurance Industry in 2014

• Regulatory approval of premium rate filings – federal and state

• Health insurers required to pay out 80 or 85% of premium dollars as claims

• New premium setting methods: increase premium rates for people under age 40 while lowering rates for people over age 40

• Health reform restricts ability to underwrite Guaranteed issue of policy to any insured No pre-existing condition limitations at time of

application

• Individual states must introduce a Health Insurance Exchange or be subject to Federal Insurance Exchange

New Value Creation

• NCQA and consumers are judging health plans on the delivery of health care services

• Healthcare Effectiveness Data and Information Set (HEDIS) scores become important (104 clinical measures)

• Consumer Awareness of Health Plan Survey (CAHPS) scores become important with consumer purchasing:

Rating of All Health Care Getting Care Quickly Shared Decision Making Rating of Personal Physician Rating of Specialist Seen Most Often

Mechanisms of Acquiring Health Insurance Coverage under the

Affordable Care Act (ACA)

Blumenthal D, Collins SR. N Engl J Med 2014;371:275-281.

Categories of Expanded Health Insurance Coverage under the

Affordable Care Act (ACA)

Blumenthal D, Collins SR. N Engl J Med 2014;371:275-281.

Health Care Reform and Psychiatry:Oil and Water? -or- Salad Dressing?

• Payment streams for psychiatric and substance use care are distinctive and poorly understood

• Scope of the relative sectors - public, commercial, direct state expenditures, self pay - are unique

• Substantial impact of medical and psychiatric co-morbidity on total cost of all medical care

Percentages of U.S. Spending on Mental Health Care, Substance

Abuse Services, and All Health Care That Were Coveredby Various Types of Payers, 2005

Barry CL, Huskamp HA. N Engl J Med 2011;365:973-975.

Medicaid Mental Health

Bending the Medicaid cost curve through financially sustainable medical behavioral integration Steve Melek Milliman July 2012

Public-Private PayerMH 1986-2014

Projections of National Expenditures for Mental Health Services and Substance Abuse Treatment 2004-2014

SAMHSA, 2008

SA ExpendituresPublic–Private 1986-2014

Projections of National Expenditures for Mental Health Services and Substance Abuse Treatment 2004-2014

SAMHSA, 2008

Health Care Reform and Psychiatry

• Payer environment is problematic

• Payment differentials are discriminatory

• The impact of commoditization and stigma on the marginal value of psychiatric services is of particular importance

• There is a larger psychiatric self-pay population

How Psychiatric Practice Differs

Avik Roy: Health Tracking Study Physician Survey

Co-Morbidity and Cost:The Impact of “Psychiatric”

Illnesson “Medical” Illness

Outcomes

Medical Psychiatric Co-Morbidity

Druss BG and Walker ER. Mental Disorders and Medical Comorbidity. Robert Wood Johnson Foundation, Research Synthesis Report No 21, February 2011. www.policysynthesis.org

Depression Rates inMedically Ill Patients

Medical Illness Prevalence %

Cardiac Disease 17-27

Cerebrovascular 14-19

Alzheimer’s 30-50

Parkinson’s 4-75

Epilepsy

Recurrent 20-55

Controlled 3-9

Diabetes

Self Reported 26

Diagnostic Interview 9

Cancer 22-29

HIV/AIDS 5-20

Pain 30-54

Obesity 20-30

General Population 10.3

39After Evans, DL et al Biol Psychiatry 2005; 58: 175-189

80

85

90

95

100

0 100 200 300 400

Time After Discharge for MI (Days)

Surv

ival

Fre

e of

Car

diac

Mor

talit

y, C

umul

ativ

e (%

)

Not Depressed (BDI < 10)

Depressed (BDI ≥ 10)

Frasure-Smith N et al. Psychosom Med. 1999;61:18-20.

Depression and 1-Year Post-Myocardial Infarction(MI) Cardiac Mortality

N = 896Odds Ratio = 3.4 (1.8-6.7)

P < .001

Copyright © 2012 American Medical Association. All rights reserved.

From: The State of US Health, 1990-2010:  Burden of Diseases, Injuries, and Risk Factors

JAMA. 2013;():-. doi:10.1001/jama.2013.13805

Number of Years Lived With Disability by Age for 20 Broad Groups of Diseases and Injuries in the United States in 2010 for Both Sexes

Combined

Copyright © 2012 American Medical Association. All rights reserved.

From: The State of US Health, 1990-2010:  Burden of Diseases, Injuries, and Risk Factors

Top 20 Causes of Years Lost to Disability in the United States

JAMA. 2013;():-. doi:10.1001/jama.2013.13805

Cost of Physical & Mental Illness

Medicaid Medical Admission Risk Stratified by

Psychiatric/Substance Use and None

Source: Steve Daviss, MD

Models of MedicalPsychiatric Integration

Integrating Medical & Psychiatric Care

– Institute of Medicine• Health care for general,

mental, and substance-use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind/brain and the rest of the body

Improving the Quality of Health Care for Mental Health and Substance-Use Conditions: Institute of Medicine 2006

Core Principles ofEffective Collaborative Care

Patient-Centered Care Teams

• Team-based care: effective collaboration between PCPs and Behavioral Health Providers.

• Nurses, social workers, psychologists, psychiatrists, licensed counselors, pharmacists, and medical assistants can all play an important role.

Population-Based Care

• Behavioral health patients tracked in a registry: no one ‘falls through the cracks.’ Population-based screening

Measurement-Based Treatment to Target

• Measurable treatment goals clearly defined and tracked for each patient

• Treatments are actively changed until the clinical goals are achieved

Evidence-Based Care

• Treatments used are ‘evidence-based’

AIMS Center 2011 From Lori Raney MD

IMPACT Study

• Multi-site randomized controlled trial

• Assessed effects of collaborative care compared to usual care in 1,801 depressed primary care patients >60 years old

• Patients with depression were identified using the Scl-20 and followed-up with PHQ-9

Unutzer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, Powers D. Long-term cost effects of collaborative care for late-life

depression. Am J Manag Care. 2008 Feb;14(2):95-100.

IMPACT Study Design

Intervention (n = 906 )• Access to depression care

manager who provided:• Education• Behavioral Activation• Support of self-care• Problem solving

treatment• Screening and follow up

Usual Care ( n = 895 )• Encouraged to follow up

with PCP for treatment.• Eligible to receive all

treatments:AntidepressantsSupportive counselingSelf-or physician-referral

to mental health specialist

Unutzer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, Powers D. Long-term cost effects of collaborative care for late-life

depression.Am J Manag Care. 2008 Feb;14(2):95-100.

Clinical Results

• At 12 months:– 45% of intervention

patients had a 50% or greater reduction in depressive symptoms from baseline compared with 19% of usual care participants

• Compared to UC, intervention pts had: – rates dep tx– rates of

satisfaction– functional

impairment– quality of life

Unutzer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, Powers D. Long-term cost effects of collaborative care for late-life

depression.Am J Manag Care. 2008 Feb;14(2):95-100.

IMPACT Study

Unutzer J, Katon WJ, Fan MY, Schoenbaum MC, Lin EH, Della Penna RD, Powers D. Long-term cost effects of collaborative care for late-life

depression.Am J Manag Care. 2008 Feb;14(2):95-100.

Psychiatry and the U.S. MentalHealth Workforce: 1972

Total MH workforce =40,000From: DHHS CMHS 2004, chap 18

Source: Ben Druss MD

Psychiatry and the U.S. MentalHealth Workforce: 2006

Total n for MH workforce =549,000From: DHHS MH United States 2010 CMHS 2011

Source: Ben Druss MD

Barriers and Next Steps

• Psychiatrists are more disconnected from existing payer systems and appear to be less likely to be in large groups or employed

• Delivery systems should apply the insights from research in medically co-morbid illness and models of care in planning for their future

• Training and education for all physicians both currently in practice and in training will be needed

Guiding Principles for Reform:The Triple Aim

• Improving the patient experience of care (including quality and satisfaction)

• Improving the health of populations

• Reducing the per capita cost of health careThe Long Term Costs of Health Care –Public and Private are Unsustainable