Succeeding In A World Of Integrated Care: Discussion Panel (Week 3)
Below you will find the Q&A discussion from the Week 3 live session:
“Business & Legal Aspects Of Making Medical/Behavioral Integration Work”
Guest presenter: Michael Goldberg, PhD, Director, Child & Family Psychological Services, Inc.
Originally presented: April 21, 2015 at 2:00 p.m.
View the Q&A transcript from weeks 1-4 using the links below:
- Week 1: “Integration Of Services In Optum’s Pain & Depression Management Program”
Guest presenter: Irvin “Pete” Brock III, M.D., Senior Vice President, Optum - Week 2: “Health Home Management”
Guest presenter: Boris Vilgorin, Assistant Vice President, FEGS - Week 4: “A Medical/Behavioral Integration Model Case Study”
Guest presenters:- Courtney Esparza, Senior Director, Behavioral Solutions, Optum
- Daniel Wilkes, Care Coordination Director, Northwest Primary Care Sellwood
- Helen Kurre, Director, Quality & Medical Practice Integration, Providence Health Plans
Clicking a question below will expand to reveal the answer and discussion during the live session.
Solo Private Practitioner – how do primary care clinics absorb the high number of Optum contracted psychologists, and how can Optum potentially help them co-locate?
George: I can’t answer for Optum but it sounds like the question is asking how to get involved in working within a primary care system in a model similar to what they’ve seen others work. That goes back to the last slide. If you’re interested and you want to work with a primary care provider system in your area, it’s perfectly okay to go talk with them about a way of becoming part of and working within that system. There are a lot of providers who end up going to the managed care or primary care provider systems first and offering their services or offering to negotiate a way of being a provider in that system. I can’t tell you specifically how Optum would respond or how they determine how to incentivize partnerships but the first step is to know what you want to do and then do the outreach.
How do we get paid for no shows or open spots in our schedules?
George: no shows are part of the dilemma. For no-shows, you’re not likely to be paid if you’re working on a fee-for-service (FFS) model. This is one of the advantages of working within a case-rate or capitated model instead of FFS, particularly if you work with a population where you’ll be putting for a lot of effort sometimes, but other times not so much effort, or, if you’re working with a population that is unreliable and you’re going to have to do a lot more outreach (which is often not reimbursed). We talked about in previous sessions that sometimes it is better and more optimal for the provider to have some kind of a per member per month (PMPM) rate or a case rate where they get paid for the case as long as it is active within the system. Otherwise, the strategy to get paid for times where you’re likely to have a no-show is to look at different types of scheduling. Other systems sometimes schedule more people in a given hour than can possibly be seen because by history it is known that a certain percentage will be no-shows. Every once in a while you will get caught with more people than you can see than you have time and you’ll have to work that out among the team of providers.
Are there any standard encounter rates for behavioral health providers who are integrated into a primary care center?
George: I don’t know about standard encounter rates. My guess is that the rates are based on the state you’re in and the system you are in.
Have you faced the problem of having an integrated system or an integrated program, such as an IOP program that involves both medical and behavioral health services, where the insurance companies begin to argue with each other over which benefit plan the IOP program falls into (medical or behavioral)? Are you left unable to get authorization to provide the care involved in the integrated program?
George: Historically I have run into some of this. Generally, when we have a program that is desirable to the managed care companies, whether it’s an IOP or other type of program, we negotiate upfront how that’s going to be paid and who is responsible for paying it. If you have multiple payers involved, where they want to deny payment and hope it falls back into a different payer’s category, you just have to make this very clear to the managed care system upfront during negotiations that if they want access you need to be reassured that you will be paid for the services provided. It’s better to be proactive about this type of dilemma.
If you were to look at lessons learned from this and what you might have done differently when you were starting out, what would you have done differently?
Michael: We may have moved sooner to modifying our electronic health record (HER). We waited on our partners to see what they were doing and we are now moving forward with a new system. That’s definitely one thing. But honestly, we don’t have a lot of regrets. We had more bugs and frustrations than we anticipated, but not many regrets.
One of the things that impressed me about your model was how you started out slowly and allowed it to evolve – did you think about those three elements of agreements from the get go, did you see them in a model for contracting somewhere, or how did that process develop for you?
Michael: To be frank, if you’re following the trends in health care the push towards integrative behavioral health has been foreshadowed for a long time. We always had the strategic plan of integrating more, but our approach was to sit back and look for the right opportunity and the right primary care partnership. I think what happened in Massachusetts (MA) was with the Medicare Pioneer ACOs and MA Blue Cross/Blue Shield contract, they came to us. Necessity is the mother of innovation. Basically we met and we hired health care lawyers and we developed a model that worked – we didn’t have anything sitting in the can for three or four years. We sat down and we problem-solved, we had a goal and we tried to develop a model that worked. Subsequently, our model has been profiled by the American Psychological Association’s Practice Organization. Legal and regulatory folks have reviewed different models to see what works from a legal and business model, there’s implicit approval by the lawyers at our APA about our model.
George: It is a really excellent model and it is out there in the literature in profile at some level. I hope we can make that available to people if it can be because you’ve addressed some of the questions and problems that I’ve heard other provider systems have once they get into those models.
As you’re thinking about doing population based management, what will that look like as a private provider? I’ve worked with public systems when I’ve helped develop population based management (along the lines of modified health homes or housing first models), but when you’re working with commercially paid for health care and population based management how are you looking at that evolving and how you might develop that as a private provider?
Michael: I think we’re really faced with answering and defining this. My concept or perception is that it’s starting with certain areas that are defined by the global payment models that primary care doctors have, and also driven by their understanding of increased medical utilization without improved medical outcomes for patients with specific diagnoses, particularly depression and anxiety. These global payment models and patient centered medical homes (PCMH) are requiring primary care doctors to screen for depression and anxiety. Once they screen for them they are required to do something about it, so some of it is systematic depression services management. But then there are also things like identifying diabetic patients (that are non-compliant or not managing blood sugars well) and referring them out, or identifying pain patients who are high utilizers of services and doing evidence based services. There are a few studies that have shown that with cancer patients with anxiety and depression have dramatically higher medical utilization without different or better outcomes. There have also been a few studies that show that very inexpensive mind/body interventions have led to increased consumer satisfaction and decreased medical utilization whilst not having any negative or positive impact on the patients’ mortality or physical outcomes. So working with the primary care doctors who are now taking on the risk for all of their treatments, I can go and say to them “give me all your cancer patients and I’ll screen them and offer them this mind/body intervention, at a lower cost, and this will decrease their medical utilization”. It’s really exciting to be able to design the systematic services that hit the consumer experience, improve outcomes, and decrease costs. Unlike managed care of the 70s-80s we’re experiencing less unreasonable efforts to put up barriers to traditional care. We’re adding things without making it harder to do the stuff we’ve always done.
George: I agree with you. And the models that we’re looking at now are more about giving people the right access to the right level of care instead of trying to restrict access. I hear you with the models and it will be interesting to see how they evolve. I know that in my experience, one of the things we did in one system was to take psychiatric nurses, who hadn’t worked with people with serious medical problems in some time, and get them retrained in some of that by a school of nursing so they could be the care coordinators or care managers for that population that you just described (serious chronic medical illnesses that also had serious behavioral health problems). It will be interesting to see how we go about designing and meeting that challenge as we go into the future.
Michael: I’m not sure exactly what the composition of the audience is today, but if there are a lot of solo practice and small groups out there, there are other alternative models rather than directly integrating. Some people out there are mistakenly threatened by groups like mine. The demand for behavioral health services, because of health care reform and increased screening, is rapidly increasing. The need for services is far beyond what we can provide. Our group, and I know other primary care integrated models, are looking for small individual practices to partner with us. We’re asking them for some systematic communication, but people who have specialties are important. We want to drive referrals to those folks, not prevent them.
How many behavioral health primary care integrated programs does Optum have and in what states are they running?
Deb: I don’t have the count off of the top of my head. Some states where we have behavioral health primary care integrated programs running are New York, Massachusetts, and Washington state. I wouldn’t say the volume is high at this point but we have a number of programs where we’re testing out the model. If folks were able to participate in week one’s discussion, the pain depression management program isn’t really limited to a state. We are using data to help identify individuals that would benefit from the program, so it isn’t really a state based program. However, some of these, like our health home model in New York, are very geared to the requirements in that state. While some of the programs are specifically coordinated with Optum and those within our provider network, we have many providers on our panel, Dr. Goldberg being one, who are doing this on their own. They are participating with us, but are also very engaged in medical/behavioral integration efforts that Optum didn’t launch or initiate; the providers are implementing them within their own businesses. I’m suggesting that this is a two-way street where many providers are moving their way towards this independently.
As a follow up to an earlier question, how many appointments for traditional therapy do clinicians schedule in a day to allow for interruptions and to maintain productivity?
George: If we’re talking traditional therapists within a behavioral health system it depends on the productivity standards; in a public practice it will generally be the 50-60% standard. In a private practice you could be as full as 80-90% or more. When we get into a primary care system then a behavioral health provider has to, depending on the three different roles, figure this out. If you are working as coordinating individual within the system your productivity may vary – you may have only a few appointments a day but you may work and do a whole lot of other kinds of coordinating within the system. If you’re working as a prescriber you may have a very specific set of 30 minute appointments for assessments and medication adjustments. I’ll turn it over to Michael to ask what his productivity expectations are for his folks who are integrated.
Michael: Many folks training for primary care (in VA, etc.) have a strict 30 minute appointment window seeing 12-16 patients a day. In our model, keeping in mind we do the integration but also try and prevent the bottle neck, we have the outpatient backup services. We allow a lot more flexibility for our providers. In our primary care site we do not allow our providers to pre-book more than 5 hours of services in a day by design to keep availability for urgent care and handoffs or consultations. They may have more than 5 billable hours because of that. However, we’re trying to promote doing our services in different ways – part of that is utilization of 25-30 minute appointments when clinically appropriate. Our providers have incentives to follow those window guidelines, but also have a lot of independent control over how those bookings happen; they could have a combination of 30 minute appointments, hour appointments, and sometimes in crisis situations 2 hour appointments.
George: That is an example of getting the right behavioral health providers working in those settings so that they fit with the culture. In those situations you have to have people who can be flexible and work within a setting that changes every day.
Michael: In our model, only 10% of our providers set foot in primary care offices. We have those folks that come out of those training sites (like the VA) with the skills and interests to practice that way, but the rest of our providers aren’t forced to change that much.
Do you find your clinicians often doing bachelor level case management (helping with social security applications or food stamp acquisitions). If so, how do you demonstrate the value of your Masters level providers?
Michael: No, we don’t. It certainly happens from time to time. Any behavioral health provider, depending on their circumstance, has helped people with applications for Medicaid or disability. However, in our model our primary care partners actually have separate case monitors. When there are complex cases needing that kind of coordination we can turn to them. But I don’t think we’re doing a dramatic amount of that kind of work.