Integration of SUD services with Primary Care Lessons

Integration of SUD services with Primary Care Lessons Learned from around the World Darren Urada, Ph. D. UCLA Integrated Substance Abuse Programs CADPAAC / ADP Quarterly Meeting Integration Learning Collaborative May 29, 2013

Acknowledgements UCLA team: Jeff Annon, Valerie Antonini, MPH, Desiree Crevecoeur. Mac. Phail, Ph. D. , Thomas Freese, Ph. D. , Sherry Larkins, Ph. D. , Brandy Oeser, MPH, Howard Padwa, Ph. D. , Diego Ramirez, Beth Rutkowski, MPH, Cheryl Teruya, Ph. D. , Elise Tran, Richard Rawson, Ph. D. Research funded by: California Department of Alcohol and Drug Programs Kern County The authors’ views and recommendations do not necessarily represent those of the funders, UCLA, or the UCLA Integrated Substance Abuse Programs.

Topics to be covered • • • Financing / Workforce Chronic Pain Performance – lessons from Britain “Hot-spotting” Coming to an exchange near you…

Financing / Workforce • With ACOs, currently non-billable BH staff like SUD counselors will essentially be “billable” if the team is credentialed. Rules still in progress and will vary from state to state. • There are 150 “pioneer” medicare ACOs right now, and CMS is awaiting data from them. At first look, not finding huge cost savings. Source: Capobioanco & Kenerson (National Council), 2013

Financing / Workforce • FQHC/BH partnership example: BH center was seeing lots of people very briefly for meds only and were getting paid $17 -$34 because billing was based on time. • In FQHCs, the National encounter rate avg is: $143/encounter. • BH center and FQHC partnered, moved the medonly BH patients over to the FQHC. Partnership brings in more $$. Source: Reynolds, 2013

Financing / Workforce • FQHCs can contract with BH and still have enough left over to pay their own expenses. • The “sell”: Doctor wants to hand off the crying patient to BH rather than that patient taking up all of the doctor’s time. For bottom line, FQHCs need to see as many pts as possible. • With BH, Doctor hands off, moves to the next patient, but the crying patient still gets quality care. • Partner. “If you’re not at the table, you’re on the table. ” Source: Reynolds, 2013

Workforce • In Nebraska, licensed mental health practitioners can bill at FQHCs. This includes social workers, MFTs, and COUNSELORS. • http: //dhhs. ne. gov/publichealth/Pages/crl_mhcs_mental_lmhprequire. aspx Source: Capobioanco & Kenerson, 2013

Financing/Workforce • • Next steps Rosenberg, Gauthier on financing. CATES meetings (finance) SARC Meeting, September 11, 2013 (workforce).

CATES follow up Webinars Topic Date Integrating Services with Primary Care June 19 Marketing June 26 Contract Negotiations July 2 Financing Strategies July 10 Developing Payer Relations July 17 Marketing July 18 Integrating Services with Primary Care July 23 Contract Negotiations July 31 Financing Strategies August 7 Developing Payer Relations August 14

Chronic Pain & Prescription Drugs

Source: Fishman (2013)

Suggestions for Reframing the Goals of Treatment • Function is primary • Happiness is important • Goal of complete analgesia is unrealistic • In fact, pain relief is not high on the list at all “You’re taking all the pain meds known to man, and are still in pain with miserable side effects. We can’t possibly do worse. Let’s try something different. ” • Not helpful to use the term “addiction” Source: Fishman (2013)

Source: Fishman (2013)

Source: Fishman (2013)

Source: Fishman (2013)

Lessons from Britain

Listen to people who use our services • ‘In Your Shoes’ sessions for staff to listen to experiences of service users and their carers • Feedback cards – simple postcard sized feedback from service users and carers • Observations of care – by staff or carers Source: Ardley, 2013

Feedback from Patients Source: Ardley, 2013

Source: Ardley, 2013

Source: Ardley, 2013

Performance • Net promoter score. Required across National Health Service. Source: Ardley, 2013

Performance • "Net Promoter Score (NPS") - Those scoring services with 9 or 10 are promoters, those scoring 0 -6 are detractors and those between 7 -8 are passively satisfied or neutral. The NPS is the difference between the percentage of users who would recommend your services minus the percentage of those who would not. • 75% or above is considered quite high. • If scores go down, a regulator comes in. If scores are good, they’re left alone.

Source: http: //www. nta. nhs. uk/

“Hot Spotting”

“Hot Spotting” • Hotspots. Identify high cost users. Who are they, where are they? Looked at home addresses of patients from 5 years of data. Costs are highly concentrated geographically. Source: Jeffrey Brenner, M. D.

Source: Brenner, 2013

One patient, two hospitals running the same tests. Insurers, docs, pts all complain about each other. It’s the system. Source: Brenner, 2013

Atul Gawande: Video about treating the needs of a high-cost patient. See: 1 hr 13 min -1 hr 17 min mark. http: //www. livestream. com/nationalcouncil/video? cli p. Id=pla_27872969 -949 e-44 b 0 -873 e-5 e 65 b 663 ddfc Source: Gawande, 2013

“Hot Spotting” • Why do hospitals like hot spotting? Doesn’t identifying, addressing high-cost patients take away revenue? 1. “You’re going to go off the cliff in the next 510 yrs. How will you succeed in the ACO world? ” 2. “We can influence doctors the most by getting patients to stop driving them crazy. ” High cost patients are not always good for their processes.

Camden, NJ Source: Brenner, 2013

Exchanges

Exchanges • 8 regional exchanges, with different plans. • Outreach - $200 million for marketing, outreach, promotion. More from foundations. • See: Coveredca. com Source: Peter Lee, Director, Covered California. Insure the Uninsured Project (ITUP) conference, 2/5/2013

Will people buy insurance? Penalties for not doing so: • 2014: $95 per adult or 1. 0% of (income minus 10 k indiv/20 k family), whichever is greater • 2015: $325 or 2% • 2016 $695 or 2. 5% • Confused? Here’s a penalty calculator: http: //www. healthinsurance. org/learn/obamacare-penalty-calculator/

Final Note • “It is important to remember that January 1, 2014 is an important day, but it is just one day; it will be tough day, month and year. ” Source: Alan Weil, Executive Director, National Academy for State Health Policy. Feb 5, 2013, ITUP Conference

References Ardley, J. (2013). Perspectives from Great Britain: Creating the customer focused culture. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 9, 2013. Powerpoint available at: http: //nationalcouncil. info/natcon 2013/handouts/TLunch 3 -Ardley-1. pdf Brenner, J. (2013). “Hot Spotting” - Ideas for psychiatrists working with high utilizers of health care. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 9, 2013. Powerpoint available at: http: //nationalcouncil. info/natcon 2013/handouts/TLT 3 -Brenner-1. pdf Capobianco, J. , & Kennerson, J. (2013). Building the integrated healthcare workforce of the future. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 7, 2013. (no powerpoint available) Fishman, M. (2013). Chronic Pain and Prescription Drug Abuse: Intertwined Epidemics. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 8, 2013. Powerpoint available at: http: //nationalcouncil. info/natcon 2013/handouts/B 1 -Fishman-1. pdf

References Gawande, A. (2013). Better: Lowering Costs and Improving Health Care. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 9, 2013. Video available at: http: //www. livestream. com/nationalcouncil/video? clip. Id=pla_27872969949 e-44 b 0 -873 e-5 e 65 b 663 ddfc Reynolds, K. (2013). Show Me the Money! Designing a Sustainable Financing Model for Integration. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 8, 2013. Powerpoint available at: http: //nationalcouncil. info/natcon 2013/handouts/A 2 -Reynolds-2. pdf Richardson, J. (2013). Show Me the Money! Designing a Sustainable Integration Financing Model. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 8, 2013. Powerpoint available at: http: //nationalcouncil. info/natcon 2013/handouts/A 2 -Richardson-1. pdf

CONTACT Darren Urada, Ph. D. UCLA Integrated Substance Abuse Programs durada@ucla. edu