Optum Behavioral Solutions - RIBGH€¦ · Optum Behavioral Health. Proprietary and Confidential. Do not distribute. BH700-092016 . Proprietary and Confidential. Do not distribute.

Proprietary and Confidential. Do not distribute. BH700-092016

Optum Behavioral Health




Commercial Medicaid Medicare

OBH Membership State of RI residents as of August 2016

Product Type Aug16 Mbrs Commercial 141,671 Medicaid 86,875 Medicare 21,671 Total 250,217

Facility Type State Count of Facility Id

Count of Facility

Addresses

Autism/ABA Agency RI 10 13 CMHC Community Mental Hlth Ctr RI 3 17

Freestanding MH IOP RI 1 2 Freestanding SA Day Treatment RI 1 6

Freestanding SA IOP RI 2 3

General Hospital w MH RI 3 5 General Hospital w MH & SA RI 4 21

General Hospital w SA RI 2 2

Methadone Maintenance RI 1 5

Outpatient Detox Center RI 1 4

Psychiatric Hospital RI 1 1

Psychiatric Hospital w SA RI 1 2 Psychiatric Residential Fac RI 5 14

Residential Treat Ctr w MH/SA RI 1 20

SA Rehab Facility RI 3 3

SA Residential Facility RI 4 9

Veterans Admin Facility RI 1 3


Bubble size = total # commercial admits

Facilities with > 15 admits

White Star = Regional Avg. (N.E.)

Black Star = National Avg.

Data based on 979 Rhode Island Commercial Inpatient Admissions

Source: MH & SUD claims data, August 2015 – July 2016


Bubble size = total # commercial admits

Facilities with > 15 admits

White Star = Regional Avg. (N.E.)

Black Star = National Avg.

Data represents both MH and SUD admits

Data based on 979 Rhode Island Commercial Inpatient Admissions

Source: MH & SUD claims data, August 2015 – July 2016



Focus on recovery and resiliency

We utilize proven “recovery principles” to

improve outcomes

Most programs fail because the underpinnings that

support behavior change are missing

Typical Medical Management Approach

Recovery-centered Approach

• Communication tools focus on consumers’ strengths and what they want to achieve, not how “ill” they are

• We create communities that treat consumers “where they are”

• Transparency of clinical effectiveness for active decision making and tracking goals

• Innovative technology that offers a variety of treatment options

• Focus on symptoms, illness and deficiencies — not personal strengths, desires and life goals

• Program compliancy — not adherent to what’s important to the consumer

• The provider is responsible for clinical progress — not the consumers and their motivated desire to reach their defined goal

• Care is limited to standard mental health services

Our person-centered approach to care is unique and powerful


MedicalAny action that eliminates a barrier between medical and behavioral services resulting in better outcomes

Behavioral Medical

MBI supports whole person care


Beh

avio

ral H

ealth

R

isk/

Stat

us


Accountable Care Organizations

Improve quality

Improve access to care

Reduce avoidable emergency visits

Reduce avoidable admissions

Improve high risk patient care

Community care team


Architect systems of care, build broad networks, and integrate care management to help create a more effective and efficient provider network

¾ We manage financial risk

¾ We ensure quality measures are met

¾ We manage clinical care

¾ We manage provider networks

Whole-person health

Population-specific interventions

Consumer and provider experience

Recovery

CORE

ELE

MEN

TS


1) Care management wrapped around individuals with chronic behavioral health conditions, in their Behavioral Health (BH) care settings

2) BH staff integrated into medical practices for screening, brief intervention and referral; currently 12 participating practices

3) Integra and Prospect CharterCARE are the two current Medicaid ACOs; their staff have access to both medical and behavioral information and can coordinate care across the continuum; access occurs through the population health registry

1) Health Homes – integrated case management in CMHO’s and Opiate treatment providers (OTPs)

2) Care Transformation Collaborative (CTC)-RI’s Integrated Behavioral Health initiative

3) Medicaid “Accountable Entities”(AE) can share savings in Total Cost of Care, which includes medical, pharmacy, and behavioral costs



•

•

• Peer-directed Programs

• Substance use programs

• Mental health program

• Internal peer coaching

19 peer locations nationwide with 426 members served in Q1 2016

Network Strategy Key Performance Indicator Report, July 2016, D. Adler


Wisconsin Peer Bridger program1 Texas Whole-Health Peer Coaches2

Rhode Island Recovery Coach program3 RI PRAISE program4

1. Results within 6 months after enrollment in peer support programs in Wisconsin compared to 6 months prior to enrollment; among 130 participants enrolled from 12/9/2009 to 12/31/11 with continuous eligibility for 6 months pre- and post-referral and at least one behavioral health claim during that period; Internal UBH Report, R.Cate, 2013.. 2. Results within six months after enrollment in whole-health peer support program in San Antonio, Texas, compared to six months prior to enrollment, among a sample of 25 participants 60 years of age or older with continuous eligibility for six months pre- and post-referral, at least two hospitalizations in the prior year, and diagnosed with both a mental health issue and a general heal th issue; enrolled in the program between 06/1/2010 and 09/30/2011; Ashenden, 2011. 3. Engagement rate among 502 member referrals to the Rhode Island Recovery Coach program made from August 1, 2014 to July 31, 2016; Rosales, 2016.. 4. Increase in ROI based on results within 12 months after enrollment in the RI PRAISE program compared to 12 months prior to enrollment; claims data from 1/1/2013 to 12/31/15.; Bruce ,2/2016.


Significant rise in utilization of 18- to 25-year-olds driven by several converging factors

1. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593-602. 2. In 2012, the rate of substance dependence or abuse among adults aged 18 to 25 was 18.9%, adults aged 26 and older was 7.0%. Source: Substance Abuse and Mental Health Services Administration. (2013). Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings (HHS Publication No. SMA 13-4795, NSDUH Series H-46). 3. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2013). Treatment Episode Data Set (TEDS): 2001-2011.

Affordable Care Act

Federal Mental Health Parity

Risk of Onset for

SMI & SUD

Higher Rates of

SUD

Increase in Overall

Opioid Treatment

Variance in Clinical

Approach

Unprepared Provider System

18- to 25-year-olds became newly eligible on parents’ employer- sponsored plans

Benefit changes eliminated substance abuse treatment limits and network restrictions

Age of onset for most MH and SUD disorders is in the second and third decade of life1

2X substance use disorder rates compared to adults 26 and older2

346% increase in all treatment admissions from 2001 to 20113

MH and SUD treatment covers wide range of philosophical and evidence-based approaches

Historically low demand and lack of coverage hindered advancement in clinical innovation


*Appleby, Julie, (2016, September 12), Study: Health Spending Related To Opioid Treatment Rose More Than 1,300 Percent. Retrieved from Kaiser Health News (http://khn.org/news/study-health-spending-related-to-opioid-treatment-rose-more-than-1300-percent/)


increase from 2002 to 20134 4X increase from

2010 to 20135 3X Heroin-related deaths are rising

Americans have a substance use disorder with

prescription pain killers

1.9M 586K 12% of all Substance Use Disorders

are Opioid Use Disorders1

It is estimated that 23% of individuals who use heroin develop an opioid addiction2

Drug addiction is now the leading cause of accidental death driven by Opioid Use Disorders3 #1

Americans have a substance use

disorder with heroin

1. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Rockville, MD: Substance Abuse and Mental Health Services Administration. 2. National Institute on Drug Abuse. (2014). Drug Facts: Heroin. Bethesda, MD: National Institute on Drug Abuse.3,4. Centers for Disease Control and Prevention, Today’s Heroin Epidemic, July 7, 2015. 5. Hedegaard H, Chen L, Warner M, Drug-poisoning Deaths Involving Heroin: United States, 2000–2013, National Center for Health Statistics Data Brief No. 190, March 2015.


There seems to be a direct correlation between overdose deaths rising and the increase in opioids being prescribed

1 Centers for Disease Control and Prevention. (2014). Opioid Painkiller Prescribing, Where You Live Makes a Difference. Atlanta, GA: Centers for Disease Control and Prevention. Available at http://www.cdc.gov/vitalsigns/opioid-prescribing/. 2 Hedegaard MD MSPH, Chen MS PhD, Warner PhD. Drug-Poisoning Deaths Involving Heroin: United States, 2000-2013. National Center for Health Statistics Data Brief. 2015:190:1-8. 3Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-826.


56% increase due to misuse/abuse of pharmaceuticals

21% increase due to illicit drug use

46% increase due to adverse reactions

Reasons for drug-related emergency visits2

Drug-related emergency room visits have soared over the last decade

increase in U.S. ER costs1

from 2004 to 2011

423%

Consequences of opioid abuse in young adults3

1. Meier B, Marsh B, The Soaring Cost of the Opioid Economy. NY Times, Sunday Review, June 22, 2013. 2. Rates reflect increases in illicit drug use and misuse/abuse of pharmaceuticals from 2004 to 2011, and increases in adverse reactions from 2005 to 2011, as reported in: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2013). Treatment Episode Data Set (TEDS): 2001-2011. State Admissions to Substance Abuse Treatment Services. BHSIS Series S-68, HHS Publication No. (SMA) 14-4832. 3. National Institute on Drug Abuse/Substance Abuse and Mental Health Services Administration: The Blending Initiative. Buprenorphine Treatment for Young Adults: Fact Sheet. Retrieved from http://www.drugabuse.gov/sites/default/files/ files/BupTx_YngAdlts_Factsheet.pdf

2X Emergency room visits have more than doubled


• Expand the recruitment of Medication-Assisted Therapy (MAT) providers

• Partnered with the State of RI to implement Opiate Treatment Health Home Programs.

• Enhance our use of age-specific peer support groups and recovery coaches

• Implementing SUDS HelpLine

• Expand “immediate access” provider network

• Promote local community-based care

• Incentive providers to improve member outcomes (e.g., bundled payment)

Substance use strategy


Small % of financial risk Large % of financial risk Moderate % of financial risk

Low Accountability Maximum Accountability Moderate Accountability

P4P/Shared Savings Contracts with Qualified Facilities and Outpatient Providers

(national footprint across all payor types)

ACOs, medical-behavioral integration in health homes

Capitation + Performance-

Based Contracting

Capitation Shared Risk

Bundled and

Episodic Payments

Shared Savings

Performance- Based

Contracting

Fee-for- Service

• SUDS Medication Assistance Therapy (MAT) Providers

• DRGs • COE Bundle Payments

“The payment approach best aligned with value is bundled payment ... Well-designed bundled payments encourage teamwork and high-value care.”

− Michael E. Porter, PhD Harvard Business School Harvard Business Review, Oct 2013


Optum Behavioral Solutions - RIBGH€¦ · Optum Behavioral Health. Proprietary and Confidential. Do not distribute. BH700-092016 . Proprietary and Confidential. Do not distribute.

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