The Promise and Progress of the ACO for Behavioral Health Integration: Current Status at Montefiore Medical Center Henry Chung, M.D. Chief Medical Officer, Montefiore Care Management Organization And Associate Professor of Clinical Psychiatry Albert Einstein College of Medicine #NatCon14 “Triple Aim” • Developed in 2007 by Institute for Healthcare Improvement • New designs are needed in the health care system that simultaneously accomplish three critical objectives: – Improve the health of the population – Enhance the patient experience of care – Reduce the per capita cost of care #NatCon14 1 Performance-Based Payments To Achieve Triple Aim • Care is fragmented instead • Performance-based of coordinated. • Each provider is paid for doing work in isolation. • No one is responsible for coordinating care. • Quality can suffer, and costs rise. payments made to a group of providers for all care. • Providers are put at risk for the amount and cost of services provided. • The performance-based payment is expected to produce efficiencies and more coordinated care. #NatCon14 2 Performance-Based Payment Alternatives Episodic Cost Accountability Traditional Fee-for-Service Minimal Pay-forShared Performance Savings Total Cost Accountability Bundled Payments Shared Savings Savings Potential for Health Plans and Customers Partial Risk Full Risk Substantial Source: The Advisory Board Company: Accountable Care Forum-Briefing for Health Plan Executives 3 #NatCon14 What is an Accountable Care Organization (ACO)? • Virtual network of healthcare providers sharing accountability for coordinated care HOME CARE • Will receive additional funds from Medicare and private payers if demonstrates high quality care at reduced costs for a defined group of patients OUTPATIENT CLINICS Five key elements HOSPITAL INPATIENT CLINICIANS HCP PATIENT 1 Coordinated care 2 Patient centered care 3 Evidence-based and outcomesbased care 4 HIT (Health Information Technology) enabled care 5 Value-based payment for care CLINICS #NatCon14 4 ACO Strategy to Bend the Cost Curve Focus on the major cost drivers Prevent Prevent Illness Illness 75% 75% of of US US healthcare healthcare costs costs are are for for chronic chronic disease disease Keep Keep Chronically Chronically Ill Ill Out of Hospital Out of Hospital Hospitals Hospitals are are largest and largest and fastest growing fastest growing part part of of healthcare healthcare dollar dollar Reduce Reduce Hospital Hospital Readmissions Readmissions 20 % of hospitalized Medicare patients are back within 30 days Coordinate and integrate care delivery From fragmented care to coordinated care anchored in primary care Pay for Value, not Volume From fee for service (do more, bill more) to fee for value (outcomes) #NatCon14 5 Medicare FFS Shared Savings Program: The National Template for ACO growth and experience managing financial risk #NatCon14 6 Pioneer ACO Financing • 60% of maximum savings are eligible in first year, gains or losses are capped at 10% of gross spending • 70% of maximum savings are eligible in 2nd year, gains or losses are capped at 15% of gross spending • Third year moves to a global prepayment • Annual Medicare spending per ACO beneficiary compared to national reference population with some regional adjustment #NatCon14 7 CMS ACO Quality Evaluation • 33 quality metrics in 4 domains: Patient/Caregiver Experience Care Coordination/Patient Safety Preventive Health At-Risk Populations • Data from patient satisfaction surveys, claims and administrative data and medical record reviews based on mix of reporting and performance relative to U.S. benchmarks #NatCon14 8 IPA and Montefiore Care Management Montefiore IPA/MBCIPA • Formed in 1995 • MD/ Hospital Partnership • Contracts with managed care organizations to accept risk • Over 2400 physician members (1877 employed) 540 PCPs 1916 Specialists CMO and UBA Montefiore Care Management • Established in 1996 • Montefiore subsidiary • Performs medical and behavioral care management delegated by health plans as well as other administrative functions, e.g. claims payment, credentialling #NatCon14 9 AHRQ Recognition of the CMO #NatCon14 10 University Behavioral Associates Initial focus on risk contracting with HMOs, PHSPs and Med-Surg IPAs Provider network – Montefiore Behavioral Care IPA Bronx, lower Westchester and Manhattan Strong psychiatric network along with psychology/social work Incentivize faculty/MDs to participate via innovative payment methodologies (contact capitation) Network Management and Development • • • Maintain and re-route care in-network Flexible reimbursement strategies (salaried providers, fee-for-service, case rates, bonuses based on achieving quality measures or surpluses) Behavioral services in primary care #NatCon14 11 Key Goals of Behavioral Care in Accountable Care • Model development for delivery of behavioral care in • • • • • primary care settings (FQHCs, case rates, FFS, grants, telephonic consultation for depression management, etc) Inclusion of behavioral health expertise in specialty settings (cancer, palliative care, transplant, cardiology, etc) Quality improvement of behavioral care Coordination of medical and behavioral care Case management services both telephonic and onsite Preliminary financial modeling and monitoring of behavioral care impact on medical costs #NatCon14 12 Montefiore ACO Interventions • • • • • • • ED Case Management Post-discharge calls Expand PCMH SNF initiative (readmissions) Care Guidance (care management) House Calls (medical home visit program) Integrated medical and behavioral care management • Clinical pathways #NatCon14 13 ACO Quality Metrics – Preventive Care Preventive Measures Source Influenza Immunization – MU Menu CQM and 2012 EHR-based PQRS Claims and Records Pneumococcal Vaccination – MU Menu CQM Claims and Records Adult Weight Screening and Follow-up – MU Core CQM Records Tobacco Use Assessment and Cessation Intervention - MU Core CQM and 2012 EHR based PQRS Records Depression Screening and Followup Records Colorectal Cancer Screening – MU Menu CQM Claims and Records Mammography Screening – MU Menu CQM Claims and Records Adults 18+ who had BP Measured in previous 2 years Records #NatCon14 14 EHR Meaningful Use Behavioral Health Quality Measures (Phase 2) • Quality metrics for chronically ill: • • • • • • Tobacco screening and cessation Weight screening and counseling Depression screening and intervention Hypertension screening Depression remission rates using PHQ9! Depression followup using PHQ9 Substance Abuse assessment in Bipolar patients Alcohol Treatment initiation and Engagement Maternal depression screening at < 6 month child visit Suicide assessment for depressed patients #NatCon14 15 CRITICAL NEED FOR BEHAVIORAL HEALTH INTERVENTIONS IN ACCOUNTABLE CARE #NatCon14 16 #NatCon14 17 Post Discharge Behavioral Healthcare Associated with Decreased Costs Benzer et al; Psychiatric Services 2012 #NatCon14 18 Druss B, AJP 2014 #NatCon14 19 Behavioral Health: Opportunity to Lead or Fall Behind? #NatCon14 20 Accountable Behavioral Care Models to Consider • Patient (Person) Centered Medical (Health) Home • • • • • (PCMH) Integration of primary care into behavioral care Integration of behavioral care into primary care Management of complex behavioral patients in behavioral health homes Consult-liaison psychiatry in medical inpatient settings that target readmissions and improves outpatient continuity? Accountable care for primary psychiatric patients? #NatCon14 21
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