St Agnes Grand Rounds October 2015 Baltimore

1. 10/14/15
1
#HITshrink
Steve
Daviss,
MD,
DFAPA
Chief
Medical
InformaCon
Officer,
M3
InformaCon,
LLC
President
&
Co-­‐Founder,
FUSE
Health
Strategies,
LLC
Clinical
Assistant
Professor,
University
of
Maryland
steve@m3informaCon.com
St.
Agnes
Hospital
October
15,
2015
How
to
reduce
readmissions
and
improve
care:
IntegraCon
of
behavioral
health
care
#HITshrink
2
•
IdenCfy
the
clinical
and
financial
impacts
of
behavioral
health
disorders
on
chronic
medical
condiCons.
•
Describe
the
challenges
involved
in
improving
clinical
and
financial
outcomes
in
paCents
with
chronic
medical
condiCons
who
also
have
behavioral
health
symptoms
and/or
condiCons.
•
List
three
things
that
can
be
done
to
reduce
hospital
readmissions
in
this
populaCon.
Learning
ObjecCves
#HITshrink
Other
Hats
I
Wear
• Chair,
APA
CommiYee
on
Mental
Health
IT
• Former
Department
Chair,
BWMC
• URAC
Health
Standards
CommiYee
• HIE
Policy
Board,
MHCC
• Clinical
Advisory
CommiYee,
CRISP
• Shrink
Rap
blog
-­‐-­‐
My
Three
Shrinks
podcast
• Book:
Shrink
Rap:
Three
Psychiatrists
Explain
Their
Work
3
#HITshrink
Fuse
Health
Strategies
LLC
4
#HITshrink
Problems
.
.
.
OpportuniCes
Sources: NAMI, APA, CMS, Project RED
mood disorders are
treated by Primary
Care doctors
35%
Of patients with a
chronic illness have a
mental illness
26%
Americans 18 and older
suffer from a diagnosable
mental disorder
40million
US adults (18-54) have an
anxiety disorder in given
year
2X Costs
Unmanaged patients
with mental illnesses
Cost Payers more than
double to manage
chronic conditions
$3T
Global disease burden for
Mental illnesses due to
disability #1 cost for
businesses (WHO)
28%
Of patients re-admitted to
hospitals related to
mental illness
5
#HITshrink
Slide
courtesy
of
Ben
Druss
MD
7
Life expectancy cut by up to 25 years

2. 10/14/15
2
#HITshrink
Across
these
top
9
chronic
condiCons,
depression
and
anxiety
go
UNDIAGNOSED
85%
of
the
Cme.
Medical Costs per Disease State
Chronic Medical
Condition
PMPM With
Behavioral
Condition
PMPM Without
Behavioral
Condition
% Treated For
Depression or
Anxiety
Expected Depression or
Anxiety Prevalence % Missed
Arthritis $871.88 $564.76 7.1% 32.3% 77.9%
Asthma $861.99 $470.05 6.8% 60.5% 88.8%
Cancer (Malignant) $1,180.96 $1,018.45 5.7% 39.8% 85.7%
Chronic Pain $1,210.56 $884.70 5.9% 61.2% 90.4%
Coronary Artery $1,305.00 $958.34 5.7% 48.2% 88.1%
Diabetes $1,110 $828.18 5.2% 30.8% 83.2%
Heart Failure $2,242.85 $1,888.11 7.0% 43.8% 84.1%
Hypertension $880.33 $588.04 5.5% 30.5% 82.0%
Ischemic Stroke $1,461.57 $1,254.68 7.7% 52.4% 85.2%
Source: http://www.ncbi.nlm.nih.gov/
Cost
Burdens
from
unrecognized/undiagnosed/Mental
Health
Cases.
8
#HITshrink
Mental
Health
Affects
Medical
CondiCons
and
Outcomes
in
a
BIG
WAY
9
#HITshrink
Slide
courtesy
of
Wayne
Katon
MD
Mitchell
et
al,
J
Hosp
Med
2010
Depression increases risk of 30-day readmission
by nearly 40%
10
#HITshrink
2008:
Chronic
condiCons
and
comorbid
psychological
disorders
For
comorbid
depression,
increased
healthcare
costs
“average
$505
per
comorbid
member
per
month
across
all
chronic
medical
condiCons
we
analyzed,
of
which
nearly
$400
is
higher
medical
costs.”
79%
For
comorbid
anxiety
condiCons,
they
“average
$651
per
comorbid
member
per
month
across
all
chronic
medical
condiCons
we
analyzed,
of
which
nearly
$538
is
due
to
higher
medical
costs.”
83%
11
#HITshrink
2008:
Chronic
condiCons
and
comorbid
psychological
disorders
12
#HITshrink
Breakdown
of
U.S.
PopulaEon,
EsEmated
Annual
Costs,
and
Cost
ReducEon
from
Managing
Behavioral
Health
CondiEons
Total
U.S.
PopulaEon
321,043,000 1
Total
Adult
U.S.
PopulaEon
234,000,000
2
EsEmated
Monthly
Per
PaEent
Cost
ReducEon
EsEmated
Total
Annual
Cost
ReducEon
PopulaEon
Total
PopulaCon
Percentage
PopulaCon
SubtotalBreakdown
by
Chronic
Disease
Diabetes
COPD
CHF
Asthma
Cancer
ArthriCs
Hypertension
Ischemic
Heart
Disease
35,314,730
14,742,000
5,100,000
25,683,440
14,483,830
53,118,000
68,094,000
14,040,000
25.6%
31.3%
36.8%
53.7%
34.1%
25.2%
25.0%
44.7%
9,040,571
4,614,246
1,876,800
13,792,007
4,938,986
13,385,736
17,023,500
282
412
355
392
163
307
292
207
30,603,055,674
22,795,667,229
7,989,312,384
64,867,672,000
9,631,615,437
49,332,326,884
59,709,585,780
3
4
5
6
7
8
9
10
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
6,275,880 11
15,581,001,758
Total
for
Top
8
Diseases
230,576,000 *
70,947,726
*
260,510,237,146
*
Costs
to
Treat
As
%
of
Costs
Cost
to
Treat
PotenEal
Savings
Milliman
EsCmate
Unutzer
CollaboraCve
Model
EsCmate
16.00%
10.00%
41,681,637,943
*
26,051,023,715
*
$218,828,599,203
$234,459,213,432
12
13
*
Actual
amounts
are
less
because
some
paEents
have
more
than
one
chronic
condiEon.
PopulaCon
Clock,
U.S.
Census
Bureau,
Retrieved
March
6,
2015
Chronic
Disease
Overview,
Center
for
Disease
Control
and
PrevenCon
U.S.
Diabetes
Rate
Levels
off
in
2011,
Gallop.com,
December
16,
2011,
Retrieved
May
8,
2013
6.3%
of
U.S.
Adults
Report
Having
COPD,
Center
for
Disease
Control
and
PrevenCon
(only
includes
reported
cases)
Heart
Failure
Fact
Sheet,
Centers
for
Disease
Control
and
PrevenCon
Asthma
StaCsCcs,
American
Academy
of
Allergy
Asthma
&
Immunology
Cancer
Prevalence:
How
Many
People
Have
Cancer?,
American
Cancer
Society
CDC:
Center
for
Disease
Control
and
PrevenCon;
(ArithiCs:
2010-­‐-­‐-­‐2012
-­‐-­‐-­‐
Data
and
StaCsCcs)
Center
for
Disease
Control
and
PrevenCon;
Hypertension
among
adults
in
the
United
States;
NaConal
Health
and
NutriCon
ExaminaCon
Survey,
October
2013
CDC:
Center
for
Disease
Control
and
PrevenCon;
(Morbidity
and
Mortality
Weekly
Report:
October
14,
2011)
Based
on
OptumHealth
Report:
Co-­‐-­‐-­‐Morbid
Behavioral
Health
CondiCons
in
PCP
PracCce
Milliman,
2013.
Economic
impact
of
integrated
medical-­‐-­‐-­‐behavioral
healthcare
Unutzer,
2008.
American
Journal
of
Managed
Care
1
2
3
4
5
6
7
8
9
10
11
12
13
ConfidenCal
Property
of
M-­‐3
InformaCon,
LLC.
Do
not
distribute
or
reproduce
without
permission.
Undiagnosed
Behavioral
Health
CondiEons
This
is
a
BIG
number
in
COST
SAVINGS.
13

3. 10/14/15
3
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Source: Cartesian Solutions, consolidated health claims data
Increased
costs
of
chronic
medical
condiCons
when
mental
illness
co-­‐exists
Dollars
14
#HITshrink
Relative risk of medical admission with & without MH and SU comorbidity
-- Maryland Medicaid Adults, 2011
None
+MH
+SU
+MH+SU
CHF
RelativeRisk
Source:HilltopInstitute,2012
15
#HITshrink
Relative risk of medical admission with & without MH and SU comorbidity
-- Maryland Medicaid Adults, 2011
None
+MH
+SU
+MH+SU
HIV
RelativeRisk
16
#HITshrink
Relative risk of medical admission with & without MH and SU comorbidity
-- Maryland Medicaid Adults, 2011
None
+MH
+SU
+MH+SU
Epilepsy
RelativeRisk
17
#HITshrink
Relative risk of medical admission with & without MH and SU comorbidity
None
+MH
+SU
+MH+SU
Diabetes
RelativeRisk
18
-- Maryland Medicaid Adults, 2011
#HITshrink
None
+MH
+SU
+MH+SU
COPD
Asthma
Pneumonia NOS
Bronchitis
RelativeRisk
19
-- Maryland Medicaid Adults, 2011
Relative risk of medical admission with & without MH and SU comorbidity

4. 10/14/15
4
#HITshrink
None
+MH
+SU
+MH+SU
Cellulitis
Septicemia
RelativeRisk
20
Relative risk of medical admission with & without MH and SU comorbidity
-- Maryland Medicaid Adults, 2011
#HITshrink
2008:
Chronic
condiCons
and
comorbid
psychological
disorders
21
#HITshrink
Behavioral Health Co-Morbidities Have Significant Impact on
Healthcare Costs
$8,000
$9,488
$8,788
$9,498
$15,691
$24,598
$24,927
$24,443
$36,730
$35,840
Asthma
and/or
COPD
Congestive
Heart
Failure
Coronary
Heart
Disease
Diabetes
Hypertension
AnnualPerCapitaCosts
No
Mental
Illness
and
No
Drug/Alcohol
Abuse
With
Undiagnosed
and/or
Untreated
MI
and
Drug/Alcohol
Abuse
Impact
on
Chronic
Healthcare
Costs
22
#HITshrink
Melek,
Norris,
&
Paulus.
Economic
impact
of
integrated
medical-­‐behavioral
healthcare:
ImplicaCons
for
Psychiatry.
Milliman,
2014
23
#HITshrink
Increased
readmissions
for
COPD,
CVA
Pooler
&
Beech,
2014
Abrams
2011:
22%
more
(COPD)
Dossa
2011:
44%
more
(CVA)
ChwasCak
2014:
24%
more
(DM)
Prina
2015:
36%
more
(all)
#HITshrink
Meaningful
Use
2015-­‐2017
2016
Guidelines
1.
Pop
Health
Mgt
2.
Care
CoordinaCon
3.
PaCent
Engagement
4.
Clinical
Decision
Support
25

5. 10/14/15
5
#HITshrink
2013
NaConal
Survey
of
ACOs,
n=257
…we
found
that
the
decision
to
pursue
integrated
models
depends
powerfully
on
the
design
of
the
ACO
payment
model,
details
of
contracts,
and
the
quality
measures
used
in
contracts.
“
”
26
#HITshrink
Slide:
Courtesy
of
Jurgen
Unutzer
MD
27
#HITshrink
Effect
of
CollaboraCve
Care
for
Depression
on
Risk
of
Cardiovascular
Events:
Data
From
the
IMPACT
Randomized
Controlled
Trial
28
Stewart,
Perkins,
&
Callahan,
PsychosomaCc
Med
2014
76:129
#HITshrink
N=551
depressed
pts
60+
yrs
>
randomized
Reference
29
#HITshrink
CollaboraCve
Care
Model
Source:
Unutzer,
UW
30
#HITshrink
31

6. 10/14/15
6
#HITshrink
Bipolar
disorder
idenCfied
in
22%
of
depression-­‐
posiCve
screens
in
postpartum
women
Source:
Wisner
2014
JAMA
32
#HITshrink
Gaynes
et
al,
Ann
Fam
Med
2010
Anxiety
disorders
are
twice
as
common
as
depression
in
primary
care.
Anxiety
Depression
Bipolar
33
#HITshrink
Risks of not addressing multidimensional
behavioral health:
misdiagnosis – mistreatment - cost - safety
34
#HITshrink
 M3
Checklist
validated
in
2009
UNC
study
 Published
in
March
2010
Annals
of
Family
Medicine
 n=647
adults
in
an
academic
family
medicine
clinic
 29
items
 validated
against
the
MINI
 overall
sensiCvity
&
specificity
=
0.83
&
0.76
-­‐Depr
=
0.84
&
0.80
-­‐Bip
=
0.88
&
0.70
-­‐Anx
=
0.82
&
0.78
-­‐PTSD
=
0.88
&
0.76
 3-­‐5
minutes
to
complete
35
#HITshrink
“…none
of
the
screens
posed
a
significant
Cme
burden
on
paCents.
In
the
one
study
that
conducted
an
implementaCon
evaluaCon,
both
paCents
and
providers
found
use
of
the
screening
tool
helpful
and
acceptable,
and
that
it
facilitated
discussion
of
mental
health
issues
in
the
clinical
encounter.”
“…only
three
of
the
fiveen
studies
were
methodologically
rigorous
enough
to
warrant
Level
I
raEngs.”
“The
likelihood
raCos
for
the
detecCon
of
PTSD,
both
posiCve
and
negaCve,
for
the
M-­‐3
indicated
that
the
M-­‐3
performed
beYer
than
the
GAD-­‐7
at
idenCfying
probable
cases
of
PTSD.”
36
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10
37

7. 10/14/15
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38
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39
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Self-monitoring of mood
and anxiety symptoms via
iTunes/Android app, or via
whatsmym3.com.
whatsmym3.com
40
#HITshrink
41
#HITshrink
Telecollaboration
Telepsychiatry
42
#HITshrink
Consulting Psychiatrists
Help Providers Treat Behavioral Health Patients
“The vast majority of people who are living with mental disorders are not able to
access psychiatric treatment. So we are looking for different ways of providing the
things we know work, so we can spread out more broadly.”15
Dr. Daniel Z. Lieberman of George Washington University Hospital
Consulting Psychiatrists
We also enable curbside consultations
with top psychiatrists, and a new way
of practicing collaborative care.
43

8. 10/14/15
8
#HITshrink
Mobile App - Member
Secure Check-Ins, Texts, and Calls
44
#HITshrink
Mobile App – Case Manager
Predictive Analytics Enables Population Management
45
#HITshrink
Based
on
this
paCent’s
personalized
profile
…
Find
the
most
similar
paCents
(or
dynamic
cohort)
from
enCre
populaCon
Analyze
what
happened
with
the
cohort
and
reasons
why
(30,000+
dimensions)
Predict
the
probability
of
the
desired
outcome
for
this
paCent
Create
personalized
care
plan
based
on
unique
needs
of
this
paCent
Summary
View
of
How
Similarity
and
At-­‐Risk
AnalyCcs
Work
Desired
Outcomes
Historical
ObservaCon
Window
PredicCon
Window
This
PaCent’s
Longitudinal
Data
Predicted
Outcome
For
This
PaCent
Dynamic
Cohort
Longitudinal
Data
with
Outcomes
46
#HITshrink
47
#HITshrink
Steve
Daviss,
MD,
DFAPA
steve@m3informaCon.com
How
to
reduce
readmissions
and
improve
care:
IntegraCon
of
behavioral
health
care.
Resources
•
m3informaCon.com
–
M3
website
•
whatsmym3.com
–
M3
Self-­‐tracking
•
bit.ly/m3appstore
–
WhatsMyM3
in
iTunes
App
Store
•
bit.ly/m3validaCon1
–
Annals
of
Family
Medecine
2010
•
integraCon.samhsa.gov
–
SAMHSA
IntegraCon
Page
•
bit.ly/m3aims
–
AIMS
CollaboraCve
Care
Center
•
fusehealth.org
–
Fuse
Health
Strategies
website
•
mindoula.com
–
Mindoula
care
coordinaCon
48