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Steve Daviss, MD, DFAPA
Chief Medical InformaCon Officer, M3 InformaCon, LLC
President & Co-‐Founder, FUSE Health Strategies, LLC
Clinical Assistant Professor, University of Maryland
St. Agnes Hospital October 15, 2015
How to reduce readmissions and improve care: IntegraCon of behavioral health care
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• 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
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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
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Fuse Health Strategies LLC
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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
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Slide courtesy of Ben Druss MD 7
Life expectancy cut by up to 25 years
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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.
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Mental Health Affects Medical CondiCons and Outcomes in a BIG WAY
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Slide courtesy of Wayne Katon MD Mitchell et al, J Hosp Med 2010
Depression increases risk of 30-day readmission by nearly 40%
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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%
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2008: Chronic condiCons and comorbid psychological disorders
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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 Subtotal Breakdown 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
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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
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* 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
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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.
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Source: Cartesian Solutions, consolidated health claims data
Increased costs of chronic medical condiCons when mental illness co-‐exists
Dollars
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Relative risk of medical admission with & without MH and SU comorbidity -- Maryland Medicaid Adults, 2011
None +MH +SU +MH+SU
CHF
Rel
ativ
e R
isk
Sou
rce:
Hill
top
Inst
itute
, 201
2
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Relative risk of medical admission with & without MH and SU comorbidity -- Maryland Medicaid Adults, 2011
None +MH +SU +MH+SU
HIV
Rel
ativ
e R
isk
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Relative risk of medical admission with & without MH and SU comorbidity -- Maryland Medicaid Adults, 2011
None +MH +SU +MH+SU
Epilepsy
Rel
ativ
e R
isk
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Relative risk of medical admission with & without MH and SU comorbidity
None +MH +SU +MH+SU
Diabetes
Rel
ativ
e R
isk
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-- Maryland Medicaid Adults, 2011
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None +MH +SU +MH+SU
COPD Asthma Pneumonia NOS Bronchitis
Rel
ativ
e R
isk
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-- Maryland Medicaid Adults, 2011 Relative risk of medical admission with & without MH and SU comorbidity
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None +MH +SU +MH+SU
Cellulitis Septicemia
Rel
ativ
e R
isk
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Relative risk of medical admission with & without MH and SU comorbidity -- Maryland Medicaid Adults, 2011
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2008: Chronic condiCons and comorbid psychological disorders
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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
Ann
ual P
er C
apita
Cos
ts
No Mental Illness and No Drug/Alcohol Abuse
With Undiagnosed and/or Untreated MI and Drug/Alcohol Abuse
Impact on Chronic Healthcare Costs
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Melek, Norris, & Paulus. Economic impact of integrated medical-‐behavioral healthcare: ImplicaCons for Psychiatry. Milliman, 2014 23
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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)
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Meaningful Use 2015-‐2017
2016 Guidelines 1. Pop Health Mgt
2. Care CoordinaCon
3. PaCent Engagement
4. Clinical Decision Support
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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. “ ”
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Slide: Courtesy of Jurgen Unutzer MD
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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
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N=551 depressed pts 60+ yrs > randomized
Reference 29
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CollaboraCve Care Model
Source: Unutzer, UW 30
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Bipolar disorder idenCfied in 22% of depression-‐posiCve screens in postpartum women
Source: Wisner 2014 JAMA 32
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Gaynes et al, Ann Fam Med 2010
Anxiety disorders are twice as common as depression in primary care. Anxiety
Depression
Bipolar
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Risks of not addressing multidimensional behavioral health: misdiagnosis – mistreatment - cost - safety
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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
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“…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.”
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Self-monitoring of mood and anxiety symptoms via iTunes/Android app, or via whatsmym3.com.
whatsmym3.com
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Telecollaboration
Telepsychiatry
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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.
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Mobile App - Member Secure Check-Ins, Texts, and Calls
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Mobile App – Case Manager Predictive Analytics Enables Population Management
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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
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Steve Daviss, MD, DFAPA [email protected]
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
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