Disclaimer: I am an advocate…but have not personally worked in a medical home model, so would welcome any experiences from the audience - Advocate for better medical care for our psych patients - Advocate for further breaking down stigma against psychiatry
http://www.spiegel.de/img/0,1020,899997,00.jpg Warsaw, WWII “ There is no health without mental health” - World Health Organization Remarkable at how little research how little formal research has been done on this topic Keyword “ Mental health home”: 21 Medline references “ Medical home”: 43535 PubMed references: Employer Perspectives on the Patient-Centered Medical Home. Clinical study to determine the safety and efficacy of a low-energy, pulsed light device for home use hair removal. 486 Medline references
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. Includes care for all stages of life; acute care; chronic care; preventive services; and end of life care 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 Enhanced access - Care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff Quality and safety Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family Evidence-based medicine and clinical decision-support tools guide decision making Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement Patients actively participate in decision-makin g and feedback is sought to ensure patients’ expectations are being met Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model Patients and families participate in quality improvement activities at the practice level Payment : recognizes the added value provided to patients who have a PC-MH and based on the following framework Reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit Pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources Support adoption and use of health information technology for quality improvement Support provision of enhanced communication access such as secure e-mail and telephone consultation Recognize the value of physician work associated with remote monitoring of clinical data using technology Allow for separate fee-for-service payments for face-to-face visits. Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits Recognize case mix differences in the patient population being treated within the practice Allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting Allow for additional payments for achieving measurable and continuous quality improvements **Medicaid: those with this insurance typically have more instability, more likely to utilize ED services; majority of those on this have multiple chronic conditions with wide psychosocial needs **Funding for IT will help push PCMH
NCQA – National Committee for Quality Assurance I want to emphasize here that in order to truly be a medical home, it is a rigorous process, not simply picking up the idea and hopefully going with it. This is one of the defining features of the medical home model and one of the reasons that not only government agencies but insurers have also jumped on board with the concept – everyone likes “numbers”
While money typically muddies the picture, keep in mind that a positive aspect of this focus is that, from a systems standpoint, people are finally looking at how to reward treating chronic conditions and not just acute/acuity of illness
Sounds like a lot of work – and it is! But the idealist in me still hopes that practitioners want to do what is best for their patients (and may actually help prevent a few grey hairs for themselves) - Another reasons various organizations are getting on board is that the data to this point shows actual improvement – it’s not just a good idea from those living in ivory towers or those that have small grants that don’t show much sustainable for the majority of the population Caveat – since most of this work has been in the pediatric realm, that is where most of the good data is. HOWEVER, it seems the lessons learned and principles for kids also works in adults CYSHCN – Children and Youth with Special Health Care Needs Medical Home index score – created by Center for Medical Home Improvement, includes many of the measures already discussed with the NCQA standards So this is great – better outcomes, decreased cost, AND families (and therefore hopefully patients) are actually happy with their care ***How often does that intersection of outcomes happen?!
You might be hearing all of this and be saying to yourself, “jeez, this sounds great, why am I not doing this” - well, maybe now is the time to really consider it I include the AAN to show that our “brain brethren” are already endorsing this idea PCHM model does NOT limit appropriate referrals to specialists - Not limiting referrals – not that I think many psychiatrists worry about this point (sometimes it’s hard enough to get the referral in the first place, but that’s b/c of other factors….) – > and NOT see the PCP as a “gatekeeper”
Provides primary care – I know that many psychiatrists feel uncomfortable even with starting basic things like meds for HTN, cholesterol, DM, but if this model was in place where we knew there could be better f/u, maybe we could provide this care sooner Typical specialist PCMH patient Receiving long-term, principal care from specialist Frequent contact Most convenient for the patient Decision should be made by patient ultimately
So how can psychiatrists fit in this model? Maybe taking some of the same principles from the PCMH and applying it with models already created (but not necessarily coordinated) in the mental health world. I see this as a great way to get the MH model off the ground in the world of psych, especially if practitioners are in a community that might be slower to change in other ways ***Key caveat – my hope (at least) would not to make psychiatry yet again cut off from the rest of the medical world, but figuring out yet another model to help those who need it most. There are differences (whether anyone wants to openly admit to it) for those with SPMI, and as such there might need to be some tweaking of other systems to get people the care they need….and maybe even transition into “traditional” PCMH models So you can see by examining these principles, and comparing them to what has already been discussed in regards to PCMH, that they are fairly similar and ultimately, I feel, have the same overall goal of improving the overall healthcare of our patient population Enhanced access and coordination of care Priority access to services: new referrals, homeless, criminal justice contact *here’s a difference in particular specific to psych – more flexibility with scheduling Extensive case management: providers are involved with primary care team * Mental health home team takes responsibility for coordinating different services (ex. day treatment, intensive case management) * Also works with inpatient services * Incorporates different objectives and coordinates care and communication to make one unifying treatment plan * Can create critical mass for advocacy and support Integration of primary and preventative services - Often those in the public center do not receive the services they need - *have a 20% reduction in life span expectancy - Actively work along with PCP - Focus on wellness and primary care Use of evidence-based practices and continuous quality improvement * While difficult in psychiatry, especially in those with chronic conditions, it is still something to truly strive for Has dynamic continuous quality improvement team Attempt to engage staff and recipients to identify and adopt new practices Few people actually receive evidence-based practices Adoption of recovery principles Participation and full participation of the recipient in all decision-making Attempts to provide/create choices for the recipient A single clinical care entity can help provide focus and clarity Family and community outreach - Goes beyond individual treatment plans - Mental health home establishes identity aligned with community’s prevailing cultures Adopts a “customer is always right” attitude recipient and family are equal partners in decision making – *This is not to say that the patient always is right in regards to wanting x or y medication to treat something that is not appropriate; instead, helpful to have the attitude that what the patient wants will more likely actually get done, and to work with that
Spectrum of management/co-management: PCP as primary manager, specialist as consultant Specialist as primary manager, PCP less involved PCP as co-manager with specialist ****NEED care coordination for this to work Situations when co-management urgently needed Patients care “belongs” to no one Patients with multiple ED visits, preventable admissions, “bounce-backs” Patients who go to PCP for urgent visits, do not receive primary care from specialists Patients who miss multiple specialty appointments Challenges: - Coordination of public and private health insurance plans to avoid fragmentation and complexity - Policies that deny payment for more than one “entity” on the same day – even if different specialties Reimbursement – capitated/case rates in certain situations may be ideal, but may discourage providers from taking on difficult cases Risk-based reimbursement? Next steps: - Communicating key concepts to stakeholders Training clinical staff in the mental health home model Piloting initiatives with innovative providers Exploring and testing reimbursement strategies
These are not my tips, but rather they are lessons learned from those who have been apart of pilot programs
Advance slowly – can even take “breaks” from change to allow people time to adjust Reward – one program even gave out giftcards for families that would come to monthly feedback sessions
Not everyone – focus more on chronic conditions
$160 million surcharge on insurance payments $160 million assessment on hospitals $220 million from general revenue Waiver being threatened Health plans and insurance co prohbiited from using helth status to set rates and restrictedvariations in rates based on industry, age and group size to araio of two to one or fewer; individual market premiums could ary based only on age and geography; one of only 5 states with guaranteed-issue rating and 7 states with a modified community rating in the individual market Sttes starting with a norm of less generous benefits and/or a sig market share for high deductible plans will have a more difficult time setting a base level of services as high as MA
Ranged from 2.9% for families in the 27-36k and 9.5% for families with 93-114k People with masshealth, medicare or option of employer sponsored coverage not eligible Penalty of 672/yr adults under 26; over 26 912/yr in ‘08
Zero percent for those below poerty level of 27,468 and full responsibility for pople with incomes more thn 500% of the poverty level For an individual earning 31k the cheapest plan can cost 9,72 in premiums and out of pocket payments
UCP breakdown FPL
MCC – preventive and primary care, emergency coverage, hospitalization benefits, ambulatory pt services, mental health services and rx drug coverage; incremntal; over 3 years, no annual or per-sickness benefit max; lifetime benefit caps; limits annual deductible to 2k per individual, 4k per family 26 y/o or 2 yrs after no independent status Section 125 allow employees to choose over wages benefits that do not cout as taxable income
No of employers offering insurance rose
Oversampling of safety net doc.s
Survey in spring ‘08 of 1,000 MA FIRSM
At BMC - 30% do not speak English as a first language; suing the state CHA provides 27% and 14% of uninsured and Medicaid mental health inpatient stays; cut 20% of inpt psych beds
State calc’d by considering aver. Cost at Mahospitals and paying 75% of that amount to encourage efficiency
ER; cost; Problems obtaining care occurred across all income levels but were concentrated among lower-income adults, particularly those enrolled in public programs. These findings are consistent with an ongoing survey of physicians in Massachusetts that found the shares of internists accepting new patients and MassHealth patients dropped under health reform, while wait times for appointments increased. 21 Covered but unable to access care 1/5 adults had been told in the last 12 mo.s that a doctor or clinic ws not ccpeting new pts or would not see pts with their type of insurance Rejection rates for low income adults and those with public insurance were double the rates for higher-income residents and those with private coverage Little change in use of ERs for non-emergency tx in those with incomes less than 300% of FPL
First Nations people living on reserves; Inuit; serving members of the Canadian Forces and the Royal Canadian Mounted Police; eligible veterans; inmates in federal penitentiaries; and refugee protection claimants.
Approximately 69 per cent of health care spending is publicly funded; the remainder consists of private health insurance spending (e.g. ambulance costs, prescription drug, dental, and vision plans) and out-of-pocket spending (e.g. both prescription and nonprescription drugs).
In 2003-04, Canada spent $6.6 billion on mental health, representing just 4.8 per cent (or $197 per person) of the total health budget. That puts Canada, along with Italy, at the bottom of the list in mental health spending by developed countries. As a share of the total health budget, Britain spent the most (12.1 per cent), followed by Germany (10), the Netherlands (8), Denmark (8), the U.S. (7.5), Ireland (6.8) and Australia (6.7).
Budget 2007 announced funding for the Canadian Mental Health Commission, with $10 million over the next two years and $15 million per year starting in 2009-10.
Federal commitment to Improving Mental Health
The program is based on the success of New York City's Pathways to Housing initiative, founded in 1992 by Canadian Dr. Sam Tsemberis. Different cities, different issues The project doesn't take a one-size-fits-all approach. The Vancouver site: focus on treatment of people with substance abuse issues Winnipeg: following people with a First Nations background Toronto: focus on homeless from immigrant or ethno-racial groups Moncton: issues faced by rural residents who end up in larger cities Montreal: helping the homeless join the workforce.
Changing Paradigms of Psychiatric Practice in an Era of Healthcare Reform Chair - Javeed Sukhera, MD Co-Chair - Sarah Vinson, MD APA Annual Meeting, New Orleans LA May 23, 2010 A Presentation of the Council on Advocacy and Government Relations Fellow Members
Unintended Consequences Mental Health Reform in North Carolina 2001-Present Robin Reed, M.D. PGY-III General Adult Psychiatry Resident 2010-2012 Community Psychiatry Fellow Department of Psychiatry University of North Carolina at Chapel Hill
• Current structure of the public mental health system in North Carolina
Public Consulting Group Report recommendations (1998/1999)
State Response: House Bill 381; State Mental Health Plan (2001/2002)
Unintended consequences (Mental Health center closings, Increased admissions at State Psychiatric Hospitals, budgeting miscalculations, (lack of savings in state hospital consolidations, community support cost overruns) and poor retention of community psychiatrists.
Where we are today (CABHA, Revised service Definitions, Antipsychotic initiative, approximating ED waits, Electronic Records,)
Current Structure of the Public Mental Health System in North Carolina
State Operated Services : State Psychiatric Hospitals, Developmental Disability Centers, and Alcohol & Substance Abuse Centers
Local Management Entities (LME) (~mental health centers): Organized over geographic areas, 24 total, state government accountable, additional county/city funding
Private for-profit and nonprofit Provider groups (private practice, University-affiliated)
http://www.ncdhhs.gov/mhddsas/lme-map.pdf = State Psychiatric Hospital
• Area Programs are not accountable to state or local governments
and are guided by local forces and priorities
• Reduce State Hospital bed capacity, including closure of Dorothea
Dix Hospital, and transfer savings to community-based resources
• State Hospital utilization is highly variable and higher than in
“ peer” states
• State Hospital and Willie M. expenditures are disproportionate:
Willie M. outpatient expenditures: $37,000 / patient / year
Everyone else (MH): $337 / patient / year
1 Willie M. outpatient = 109.8 MH outpatients
• Financial data systems flawed
House Bill 381 & State Mental Health Plan (2001)
HOUSE BILL 381
Area Programs are not accountable to state or local governments and are guided by local forces and priorities.
Area programs, renamed, Local Management Entities (LME)
Reduce State Hospital bed capacity, including closure of Dorothea Dix Hospital, and transfer savings to community-based resources.
DHHS Secretary has a redefined role
Instructed to divest clinical staff and reformulate clinician contracts with ‘private’ providers
“ The ideal LME provides no direct services, concentrating its attention on developing and overseeing service provision throughout its entire region.”
Eliminate state psychiatric hospital adult beds, realign funding, and continue to develop community based services for currently hospitalized persons including specialized residential services, community nursing facilities and other supports.”
“ An Act to Phase in Implementation of Mental Health System Reform at the State and Local Level”. Session Law 2001-437. House Bill 381. General Assembly of North Carolina. Session 2001.
State Plan 2001: Blueprint for Change . November 30 th , 2001.
State Plan 2002: Blueprint for Change . July 1 st , 2002.
“ Report Card on the Clinical Impact of North Carolina’s Mental Health Reform”. North Carolina Psychiatric Association. June 2005.
“ An Analysis of State-Operated Hospital Downsizing in North Carolina”. Presentation by the Clinical Services Support Workgroup of the North Carolina Council of Community Programs and Approved by the Board of Directors of the North Carolina Council of Community Programs. 2005.
“ There Is Not Enough Money for Mental Health”. The Second Report Card by the North Carolina Psychiatric Association. March 16 th , 2006.
“ Discarding Community Psychiatrists”. The Third Report Card by the North Carolina Psychiatric Association. April 18 th , 2006.
“ Compromised Controls and Pace of Change Hampered Implementation of Enhanced Mental Health Services”. Final Report to the Joint Legislative Program Evaluation Oversight Committee. Report Number 2008-05-3. July 29 th , 2008.
“ Caring for Previously Hospitalized Consumers: Progress and Challenges in Mental Health System Reform.” Final Report to the Joint Legislative Program Evaluation Committee. Report Number 2008-12-04. December 10, 2008.
“ A History of Mental Health Reform in North Carolina”. North Carolina Center for Public Policy Research. March 1 st , 2009.
“ How North Carolina Compares, A Compendium of State Statistics”. North Carolina General Assembly Program Evaluation Division. June 2009.
“ Proposed Report on the Continuation and Expansion of Budgets 2009-2011” . House Appropriations Subcommittee on Health and Human Services. June 4 th , 2009.
“ Enhanced Services Package Implementation: Costs, Administrative Decision Making, and Agency Leadership”. Final Report to the Joint Legislative Program Evaluation Committee. July 6 th , 2009.
“ Lessons from Mental Health Reform in North Carolina, 2001-2008”. Harold Carmel, MD. 2009.
“ Critical Access Behavioral Health Agency”. North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services. March 10 th , 2010.
administrative hassles, cost, low reimbursement rates for Medicaid and CC, coverage gaps, insufficient providers
Many expressed support for a Single Payer Option
Concept is good. Implementation is weak based on the very low reimbursement rates on the Commonwealth Care plans. Access is also poor most likely due to the reimbursement issue Private Practice Psychiatrist Access to treatment for co-morbid medical & substance use disorders has improved with insurance reform & has made a huge difference for poor & previously uninsured persons with major mental illness. Public Sector Psychiatrist Source 11
Gradually increases Medicaid rates to Medicare rates for primary care providers
Prohibits lifetime benefit limits
Requires insurers to devote at least 85% of premiums in the large group markets and 80% in the small and individual markets to medical benefits, or provide consumer rebates if medical-benefit spending falls below this percentage
Establishes pilot programs to test new strategies for improving quality while reducing costs
Accountable care org.s, global payments, med. homes
Health Care and Affordability Conference Committee Report. http://www.mass.gov/legis/summary.pdf
Doonan, Michael. Tull, Katharine. Health Care Reform in Massachusetts: Implementation of Coverage Expansions and a Health Insurance Mandate. The Milbank Quarterly, Vol. 88, No. 1, 2010 (pp 54-80)
State Health Workforce Profiles: Massachusetts. U.S. Department of Health and Human Resources: Health Resources and Services Administration. ftp://ftp.hrsa.gov/bhpr/workforce/summaries/Massachusetts03.pdf
Commonwealth Connector Authority 2009. Commonwealth Health Insurance Connector Authority Affordability Information Sheet https://www.mahealthconnector.org/portal/binary/com
Commonwealth Connector Health Insurance Authority. 2009. Facts and Figures. https//www.mahealthconnector.org/port/site/connector
Long, Sharon. Stockley, Karen. Health Reform in Massachusetts: An Update on Coverage and Support for Reform as of Fall 2008. Urban Institute. 2009
Steelfisher, Gillian. Blendon, Robert et al. Physicians’ Views of the MA Health Care Reform Law – A Poll. New England Journal of Medicine. 2009; 361(19):e39.
Long, Sharon. Stockley, Karen. Massachusetts Health Reform: Employer Coverage From Employees’ Perspective: Access to coverage has grown—even as some workers in small firms have faced higher contributions to premiums. Health Affairs Web Exclusive. 2009;28(6):w1079–87.
Gabel, Jon R. Whitmore, Heidi. Et al. After The Mandates: Massachusetts Employers Continue To Support Health Reform As More Firms Offer Coverage Bay State employers have fewer reservations about the reform than they did last year, shortly after the reform took effect. Health Affairs. 2008; 27 (6) :w566–w575.
Vinson, S. Massachusetts Psychiatrists Survey – unpublished
Massachusetts health Reform: Lessons Learned about the Critical Role of Safety Net Health Systems. National Association of Public Hospitals and Health Systems. Issue Brief April 2009.
Krasner, Jeffrey. Health Provider Predicts Big Loss; Hospital alliance cites impact of reform law; Could cut 300 jobs, suffer $25m shortfall. The Boston Globe. March 17, 2008.
Kowalcyk, Liz. Boston Medical sues state for funds. The Boston Globe. July 16, 2009.
Long, Sharon. Masi, Paul. Access And Affordability: An Update On Health Reform In Massachusetts, Fall 200. Health Affairs. 2009. 28 (4): w578–w587 .
Blendon, Robert J., et al, “Massachusetts Health Reform: A Public Perspective From Debate Through Implementation,” Health Affairs. 2008. 27(6 ): w556-562. (published online 28 August 2008; 10.1377/hlthaff.27.6.w556).
Long, Sharon. Masi, Paul. Access to and Affordability of Care in MA as of Fall 2008: Geographic and Racial/Ethnic Differences. Urban Institute.2009
Goodnough, Abby. Massachusetts Takes a Step Back from health Care for All. New York Times. July 15 2009.
Lazar, Kay. Immigrants face hurdles with new care coverage: network changes, delays vex clients. November 5, 2009.
Goldberg, Carey. Mental health liaisons laid off: Agency loses 100 case managers; more cuts feared. The Boston Globe. January 8,2009.
Patient Protection and Affordable Care Act. http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590enr.txt.pdf, docs.house.gov/rules/hr4872/111_hr4872_amndsub.pdf.
Mental Health Promotion & Illness Prevention: The U.S. and Canada Margaret Balfour, MD, PhD University of Texas Southwestern Medical Center at Dallas Catherine Krasnik, MD, PhD McMaster University Medical Centre, Hamilton, Ontario APA/BMS Fellows in Public Psychiatry
Wait times for specialty appointments and procedures
Mental health care
Physicians paid to do prevention counseling (this varies by province)
*drug coverage is not included unless you have third party insurance or are on social welfare
*allied health professionals not included (e.g. psychologists, unless part of mental health clinic)
Share of Health Budget Spent on Mental Health (2003-04) Expenditures on Mental Health and Addictions for Canadian Provinces in 2003-2004 Canadian Journal of Psychiatry, May 2008; 54(5):306-13 Canada spent $6.6 billion on mental health = 4.8% of total health budget; $197/person
Current State of Canadian Mental Health Prevention
Initially leader in Preventive Care
Canadian Task Force on Preventive Health Care (1976); never in mental health though
Last of G-8 countries to develop a National Mental Health Strategy
Several programs in place (not all of them evidence-based)
Still Reactive vs. Proactive Care
Focus on Individual vs. Community/Populations
Collaborative Mental Health
Integrating mental health into primary care (e.g. Hamilton, Ontario)
Screening at Schools, community centers, church communities
$10 million federal funding at inception; $15 million for subsequent years
Advisory Group made up of people with lived experience of mental illness & addiction, family members, health care providers and researchers. Reflective of range of perspectives, such as children and youth, aboriginal peoples, seniors, women and adults, and in the workplace.
15 mtgs in 12 cities; all stakeholder constituencies
electronic consultation with stakeholders & general public
1700 individuals and >250 organizations submitted
Linking chronic disease, social determinants, mental health
E.g. Chronic disease prevention framework includes looking at schizophrenia & depression as risk factors for diabetes
Toward Recovery and Wellbeing: A Framework for a Mental Health Strategy for Canada. Mental Health Commission of Canada (2009)
Greater emphasis on addressing social determinants of mental health
“ At Home” Homelessness studies across 5 major Canadian cities (pilot research studies)
Largest study of its kind; $110 million federal funding
Determine the value of providing housing first -- and then following it with rehabilitation and treatment -- for those who are homeless and mentally ill.
Altogether 1,350 people in Moncton, Montreal, Toronto, Winnipeg and Vancouver will be provided housing, and close to 1,000 other people will be provided health and social services but won't receive housing.
Psychoeducation and supporting families & whole communities
Toward Recovery and Wellbeing: A Framework for a Mental Health Strategy for Canada. Mental Health Commission of Canada (2009)
Professor Associate Member, Department of Family Medicine Director of Programs, Hamilton Family Health Teams
Dr. Harriet MacMillan
Professor, Psychiatry & Behavioural Neurosciences and Pediatrics
David R. (Dan) Offord Chair in Child Studies Associate Member, Clinical Epidemiology & Biostatistics Associate Member, Psychology Member, Offord Centre for Child Studies Member, Child Advocacy and Assessment Program