Optum Discussion Week 4

Succeeding In A World Of Integrated Care: Discussion Panel (Week 4)

Below you will find the Q&A discussion from the Week 4 live session:

“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

Originally presented: April 28, 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 3: “Business & Legal Aspects Of Making Medical/Behavioral Integration Work”
  Guest presenter: Michael Goldberg, PhD, Director, Child & Family Psychological Services, Inc.

Clicking a question below will expand to reveal the answer and discussion during the live session.

At Northwest Primary, how are you getting paid for care coordination? Does your clinic see people on a sliding scale?

Daniel: Currently our coordination program is paid for by a grant through CMS as part of the Comprehensive Primary Care Initiative. That grant runs out in four years, we’re in year two currently, and obviously we’ve been having in-depth conversations about how to make our program sustainable. We’re exploring this in a variety of ways: there’s a Senate bill that supports care coordination on the state level; shifting priorities within our follow-up for patients discharged from the hospital to focus on those who are at-risk first, so we can show better results; and increasing our partnership with our public and commercial payers, working with them on quality initiatives and utilize our care coordination team to inspire them to help us out once the grant runs out. We don’t have anything set in stone right now, but we’re open to ideas. To address the second part of the question, we see mainly those who are insured, however we do see people who are uninsured and we have a discounted rate for those individuals. We see Medicaid users through a particular CCO.

How do you measure the clinical benefits and positive outcomes of the integration efforts in primary care? Does CMS require you to use a bio-/psycho-/or social-behavioral outcomes measure?

Daniel: Through the behavioral integration program that we are working with Optum and PHP on, there have been suggestions on how to develop conditions based interventions, we do PHQ 9 with our patients through meaningful use and CPCI. We measure the success of our care coordination efforts through certain measures like: readmission rates (both before and after care coordination involvement), ED utilization, and certain measures like that. We’re able to gauge the number of patients who are risk stratified at a higher-risk and to graduate those folks out of care coordination either through a reduced risk-level or maybe they’ve stabilized a social concern we had.

George: Do you have any outcome data available yet?

Daniel: Yes we do. The program I mentioned before, Emergency Department Information Exchange, has thrown some of our data of since they are giving us all kinds of data.

George: is it available for the listeners to access online so they can see the effectiveness of the program?

Daniel: We don’t host that on our Northwest Primary Care internet page, but we do provide some of that information in our lobby which we share with our visitors. I’ll get that to you, George, or Dustin, so that the listeners can see some of the measures and how effectively you are working.

Courtney: We’re in the process right now of pulling together our evaluation of the Phase I of the integration specialists whether they’ve made any significant impact across the four medical homes, and we’d be happy to follow up with you on that as well.

What was the most common cause of the resistance against buying into the integration model among the primary care providers

Daniel: I think, just like with most things, the idea is so brand new, it was difficult for the providers to understand early on what the new person and new role was going to provide for their patients. We had a job description laid out, but not really a work flow. We had to do a good job of building relationships with our providers and our care coordination team. Additionally, I think the providers saw some of the measurement tools as added work initially. In a lot of ways primary care is a whipping post of the medical world and they get a lot of things thrown at them. We really made an effort to show our providers how our care coordinators could offload some of that work and they could get to what they needed to get to medically during their 15-20 minute window with a patient, and that the other piece that required more time and more investment our care coordinators could team with them on.

Courtney: To piggy back on what Daniel just said, I think across the board, when talking to our primary care physicians, time was a big factor that came into play. To share a story from a physician, the last time they administered a PHQ-9 and shared results during the 15 minute interview, the patient broke out into tears and was there for an additional 30 minutes and they couldn’t get him out of the office. The primary care physician was just beside himself in knowing what to do when he opened that ‘can of worms’. This is just an example of what it feels like, from their viewpoint, to open the behavioral health ‘can of worms’ in the middle of a 15 minute session when they need to go through the medical things and get out of there.

George: It sounds, Daniel, you did a good job of showing how the coordinators can take on some of that time issue which becomes pretty vital. The primary care model these days is one that requires providers to see 30 or more people during a full-day, and to go in and out of exam rooms fairly quickly. Thus the role of the coordinator can go one of two ways: they are part of the team helping or they are someone who is just adding to the primary care physician’s burden. Daniel, it sounds like you sold the idea of the care coordinator as part of the team that will helps with the workload.

Daniel: That’s well said. It took time to do it – it wasn’t instantaneous – but that’s where we are right now.

Helen: One of the things I would add is that Courtney and I have a lot of conversations about which groups would be best to approach with this type of plan. We were very thoughtful about which groups were good partners and would be open to doing some innovation. Those are the groups that we ultimately approached.

Knowing what you know now, 2 years into the project, what would you do differently, if you were to do it again, or what would you improve within the current model as next steps?

Courtney: We are getting ready to move this project into some additional medical homes and we’ve been spending a lot of time thinking about what we need to do differently as we get ready to implement. The think that pops into my mind first a foremost is the need for flexibility. As you develop a program or new line of service, you have your ideas about what you want to do and how it’s going to go, and in our case we even vetted it in many areas, but you have to realize that it doesn’t always, or just doesn’t, go according to plan. In our case, being able to be flexible and make changes to the program (incorporating changes, etc.) can require moving at a slower pace. We implementing 50% or less of what I thought we would accomplish. Understanding that our eagerness and our misunderstandings of how the primary care practices operate we’ve built in more realistic timeframes to our projects.

Helen: This was a very innovative approach with a great partnership that we were excited and worked well. We mentioned earlier that we were working on integrating the primary care piece of the puzzle, but there were other levels of integration we were working on that were slower – like integrating our health plan. I think if we had the health plan in place it would have strengthened the integration with the primary care providers and it would have been a more effective and efficient overall program.

Daniel: As far as the private plan that we’re working on now with Providence and Optum, I would say that it would be better to have a clear understanding of what the partnership looked like. Clearer expectations and outcomes would have been helpful. As we’re nearing the end of our involvement with this project we feel pretty satisfied with what we accomplished.

When you’re looking at this at long-term financial viability (once we pass the grants, or looking at expanding without grants) how will this work for your organization, Helen, or how will you, Courtney, encourage provider systems to consider doing this even if there isn’t the grant funding?

Helen: That’s a great question. Daniel spoke a bit about metrics, and one of the metrics that we are looking at within the health plan is total cost of care. We enter into contract arrangements with various primary care groups that can deliver shared savings on total cost of care; that is our model for funding. Some of the models have a fee-for-service based system that allows for primary care providers some flexibility for innovative approaches (for example, telehealth care). We’re waiting with baited breath for what is happening in the payment world. It seems like it’s shifting from fee-for-service to quality or value based care and this is the type of payment model where this kind of project would thrive.

George: So you’d be very open to moving toward a value based reimbursement model instead of a fee-for-service model assuming it was viable to you, especially if it helps reinforce doing this coordinated level of care?

Helen: Sure and we have a long history of doing this in Medicare advantage. I think that the challenge is that when we go to the primary care group and talk about being able to fund some innovative models, the key piece is that there is no new money in the system and we can’t create it. There has to be a savings to be able to fund and strengthening primary care but we have to do our homework about where we are going to get that savings on the back end.

Deb Adler, Optum: Our approach has been to follow the reimbursement continuum, which we presented on one of the previous webinars, and move our providers from fee-for-service towards more accountable and complex arrangements including caps with pay-for-performance. In several places our approach with a health home has been to use performance metrics to help guide our way. If we can affect some of the high cost services, ER visits, readmissions etc., we can enter into shared savings arrangements with our providers.

George: That’s been my experience with any care coordination model. Eventually to make it viable in the long-term you have to look at the cost savings and where they are coming from and design a model that would pay for it through those cost savings since you won’t be getting new money. You can realign the money and establish different incentives for the system.