HOSPI TALS + PHYSI CI ANS + HEALTH PLANS

h f m a . o r g / l e a d e r s h ip

July 2017

THE BEHAVIORAL HEALTH CHALLENGE ALSO INSIDE THIS ISSUE: •• Roundtable: Integrating behavioral health care and primary care

•• Virtual visits come of age •• Dealing with policy barriers to team-based care

Jeannine Herbst, executive director of the Behavioral Health Service Line at Advocate Health Care, oversees a program that ensures inpatients older than 65 get screened for depression and anxiety. That is among the strategies providers are using to enhance their approaches to behavioral health care. See page 4.

69

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CONTENTS

4

INCORPORATING VALUE IN BEHAVIORAL HEALTH Working out the details of valuebased behavioral health models is challenging, experts say, but the benefits are worth the effort: lower costs, higher-quality care, and healthier patient populations.

DEPARTMENTS DATA CENTER 9

PERCENTAGE OF PEOPLE WITH A USUAL PLACE TO GO FOR MEDICAL CARE

CONSUMERISM 14 VIRTUAL VISITS COME OF AGE

INNOVATION

HEALTHCARE CHALLENGE ROUNDTABLE 10 INTEGRATING BEHAVIORAL HEALTH CARE AND PRIMARY CARE Healthcare finance, clinical, and health plan leaders discuss strategies for integrating behavioral health care in a way that enhances patients’ long-term health outcomes. 13 INFOGRAPHIC: A FRAMEWORK FOR INTEGRATED BEHAVIORAL HEALTH CARE

16 THE NEW KNOWLEDGE MATCHMAKER

POLICY 18 OBSTACLES REMAIN FOR TEAM-BASED CARE

M&A 20 HOW CONSOLIDATION IS RESHAPING HEALTH CARE

LEADERSHIP PERSPECTIVES 23 CONNECTING THE DOTS Joseph J. Fifer, FHFMA, CPA, president and CEO, HFMA

COMING SOON

DIGITAL EXCLUSIVES

The September issue of Leadership will examine real estate strategies that can help healthcare organizations enhance the value of care by lowering costs and improving quality.

Much more content is available at hfma.org/Leadership, including:

HEALTH CARE 2020 HFMA’s four-part Health Care 2020 series examines key trends: Transition to Value, Consumerism, Consolidation, and Innovation. Download the free reports at hfma.org/Healthcare2020.

•• Assessing the financial impact of MACRA on an organization

•• Preparing for mandatory bundled payments for cardiac care

•• Leadership Blog: Why direct primary care works for me

•• “Voices in Healthcare Finance” podcast: On the scene at HFMA’s ANI 2017

LEADERSHIP  July 2017

COVER STORY

3

4

COVER STORY

LEADERSHIP  HFMA.ORG/LEADERSHIP

INCORPORATING VALUE IN BEHAVIORAL HEALTH CARE Working out the details of value-based behavioral health models is challenging, experts say, but the benefits are worth the effort. By Karen Wagner In 1996, the Institute of Medicine issued a report on primary care that advocated for the integration of behavioral health care to improve patient health. The report also recognized the need to finance the diagnosis and treatment of mental illness in primary care settings.1 More than 20 years later, a separation of care still exists largely due to an entrenched culture of behavioral health carve-outs and a lack of financial incentives for integrated care. There is, however, movement toward integration as more healthcare professionals recognize the need to address the impact of mental illness on chronic conditions such as diabetes and cardiovascular disease. The main catalyst has been the value-based directive to provide better-quality, cost-efficient care. When providers are paid based on patient outcomes, then all factors related to those outcomes should be addressed—and studies have shown that behavioral health greatly affects outcomes and costs. Increasingly, payers and providers are planning and implementing payment models that incentivize behavioral care. Working out the details of value-based behavioral health models may take time, but advocates say the efforts are worth it—costs decline, care improves, and patients get healthier. STARTING FROM SCRATCH When it comes to healthcare costs, psychiatrist Jeffrey Weilburg, MD, sees unmet behavioral care needs as the biggest piece of low-hanging fruit. Significant progress has been made in improving the quality and cost efficiency of medical care, says Weilburg, medical director for the Massachusetts General Physicians Organization, a multispecialty group affiliated with Massachusetts General Hospital in Boston. “There still haven’t been enough resources applied to mental health,” he says. As overseer of the mental health unit of the MGH Intensive Case Management Program, Weilburg sees what happens with high-risk, high-cost patients who have both chronic medical and behavioral health conditions. If their behavioral health conditions go untreated, these patients often seek care in the emergency department (ED). Indeed, according to research by The Commonwealth Fund, ED visits and hospital stays among high-need adults (those with three or more chronic conditions and a functional limitation that hinders their ability to care

for themselves) are higher for those with a behavioral health condition than for those with medical conditions only.2 Screenings are often used in population health management to limit high-cost care and reduce utilization. In behavioral health, the PHQ-9 (patient health questionnaire-9) screens for depression. The problem is that if a patient screens positive, primary care practices often are ill-equipped to follow up. “You can’t just screen,” Weilburg says. “You really have to beef up the availability of follow-up services and treatments to make the screening itself useful. So there are administrative solutions like screening and early identification, but they can’t stand alone.”

THE PREVALENCE OF BEHAVIORAL HEALTH CONDITIONS IN HIGH-NEED ADULTS More than half of high-need adults (those with three or more chronic conditions and a functional limitation that hinders their ability to care for themselves) have a behavioral health condition among their chronic conditions.

56% 44%

High-need adults without a behavioral health condition Estimated 5.2 million people

High-need adults with a behavioral health condition Estimated 6.7 million people

Source: Courtesy of The Commonwealth Fund. Used with permission. Based on data from the 2009-11 Medical Expenditure Panel Survey as analyzed by C.A. Salzberg, Johns Hopkins University.

5 LEADERSHIP  July 2017

As with medical care, care management and coordination are vital to ensure sustained treatment and steady improvement in a patient’s behavioral health. “There’s a need for better integration of extended services and short-term primary care services, better communication, better administration of the benefit,” says Patrick Gordon, associate vice president for Rocky Mountain Health Plans, Grand Junction, Colo., which covers about 232,500 members primarily in the Colorado area. “There’s no continuum there really with respect to the needs of the patient. And that’s a much bigger challenge.” An underlying reason for the insufficiency of behavioral care is funding. Treating behavioral conditions requires a team of mental health providers—such as social workers, care coordinators, and psychiatrists— who traditionally are not part of a primary care practice. “One of the biggest issues is there is not a lot of historical support for that type of delivery model,” Gordon says. Because medical and behavioral care have been delivered and funded through different delivery and payment structures, integrating behavioral and primary care means building new structures from scratch. There is no volume-based history nor an understanding of the specific behavioral health needs of the population or what mix of providers is necessary. “The hardest part is getting it off the ground,” Gordon says. “There is no cost structure, so you’ve got

to essentially go out and create one.” Finding primary care practices that are willing to go through this learning process and then share performance data on their behavioral services is an even greater challenge, Gordon says. MOVING TOWARD VALUE Despite such challenges, public and private healthPatrick Gordon, associate care organizations have vice president, Rocky begun to take steps to Mountain Health Plans integrate behavioral services into primary care, in some cases using value-based incentives. In January, the Centers for Medicare & Medicaid Services (CMS) issued new Medicare Physician Fee Schedule codes that support integrated care. Physicians and other practitioners will be paid for providing behavioral health services such as screenings and care management support for patients undergoing treatment. In doing so, CMS says it recognizes that behavioral health integration improves outcomes for those with comorbid conditions.

July 2017

EDITORIAL AND PRODUCTION

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Leadership (ISSN: 1948-089X) is published by: HFMA Learning Solutions, Inc. 3 Westbrook Corporate Center, Suite 600 Westchester, IL 60154-5732 Phone: 708-531-9600 The Leadership initiative includes a print newsletter that is published six times a year, exclusive digital content, a monthly e-newsletter, and more. Sign up to receive the free monthly e-newsletter—and regular updates—at hfma.org/leadership. ©2017 HFMA Learning Solutions, Inc., a subsidiary of the Healthcare Financial Management Association. Material published in Leadership is provided solely for the information and education of its readers. HFMA Learning Solutions, Inc. does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions in the articles are not those of HFMA Learning Solutions, Inc. References to commercial manufacturers, vendors, products, or services that may appear in such articles do not constitute endorsements by HFMA Learning Solutions, Inc.

6 LEADERSHIP  HFMA.ORG/LEADERSHIP

In April, the New York State Office of Mental Health and the state’s Office for Alcoholism and Substance Abuse launched the Behavioral Health Value Based Payment Readiness Program. The program will fund New York behavioral health providers in the formation of Behavioral Health Care Collaboratives (BHCCs), which are partnerships such as independent practice associations that will be designed to improve health outcomes, manage costs, and help members participate in valuebased purchasing arrangements. The funding—up to $60 million over a three-year period—will support the development of a shared infrastructure and functionality for BHCC members, including clinical quality standards, data collection, analytics, and reporting. Two years ago, the state of Arizona began consolidating agencies that manage medical and behavioral health services for its Medicaid population. The strategy involved integrating private managed care contracts for behavioral and medical services and integrating care at the provider level. Such integration enables value-based purchasing, says Beth Kohler, deputy director of the Arizona Health Care Cost Containment System, which administers the state’s Medicaid program. Under one incentive program, providers at clinics where 40 percent of business is from behavioral services receive a 10 percent increase in their Medicaid payment rate for medical care to account for providing more-complex services. The state’s managed Medicaid providers are also incented to engage in value-based purchasing: Beth Kohler, deputy Behavioral health contracdirector, Arizona Health tors are expected to have Care Cost Containment 15 percent of spend be System value-based, with the number rising to 25 percent next year. The goal is to determine what works and what doesn’t, Kohler says, and to derive some lessons for value-based integrated care. “Nationally, these arrangements are evolving significantly, and what we really wanted to ensure was that our managed care organizations have the opportunity to innovate and be leaders in this space,” she says. PRIVATE-SECTOR EFFORTS Rocky Mountain Health Plans has been using a global payment model since 2012 to integrate the delivery and payment of behavioral and medical services for participating primary care practices. The practices have both upside and downside financial risk, losing part of the global payment if costs exceed the payment. Savings are also shared with participating community health centers that support the

coordination of behavioral and medical care. Performance metrics evaluate aspects of care such as depression screening, continuity of care, patient adherence to treatment, and documentation. Gordon says the payment model has produced positive results, but the long-term impact is yet to be seen. Deb Adler, executive vice “We know that these president, Optum practices tend to perform better financially and on patient satisfaction scores, screening ranks, and clinical quality measures, but whether we’re really reversing some of the adverse trends with health behaviors, depression, addiction, those sorts of things, that’s still an open question,” Gordon says. As a managed care organization, Optum, Inc., a subsidiary of UnitedHealth Group, has launched various value-based approaches to help incent medical providers—including primary care practices—to integrate care with behavioral health providers, says Deb Adler, Optum’s executive vice president for network strategy. “The reason we really feel we have to incentivize this approach through enhanced payments and value-based contracts is we want to get more of the medical providers and behavioral providers engaged in solving and improving the outcomes for members across those medical/behavioral health needs,” Adler says. The new CMS collaborative care codes will be useful in helping to support Optum’s primary care providers that offer integrated care and in engaging new providers to the cause, Adler says. Optum has also been participating for about a year in an enhanced payment model to promote integration. The program involves about 20 primary care practices in New York state. Payments help fund a Collaborative Care Center to which primary care providers can refer their patients as a source of support for members with complex behavioral health needs. Individuals are screened and identified for participation in a collaborative care program, which includes both on-site and virtual psychiatrists, a behavioral healthcare manager, and a psychologist. The enhanced payment program is a joint effort with other managed care payers, but Optum has the majority of members, Adler says. Participating practices already have seen reductions in patient stress, anxiety, and depression based on measurements such as the GAD-7, a tool used to measure improvements in such conditions, Adler says. “We are still evaluating the impact on total cost of care,” she says. Generally, the impact of addressing behavioral health needs on total cost of care is considered significant,

538

513

7

High-need adults with behavioral health condition

High-need adults without behavioral health condition

Total adult population

183

Emergency department

“We want to get more of the medical providers and behavioral providers engaged in solving and improving the outcomes for members across those medical/behavioral needs.” — Deb Adler, Optum

primary care physicians on how to manage behavioral health patients. “The primary care provider is still the driver of the overall care, and the behavioral health care, but he is getting support from a psychiatrist as well as the embedded psychologist, who is providing psychotherapy and other support,” says David Kemp, MD, medical director of Advocate’s Behavioral Health Service Line Recognizing a shortage of behavioral health providers, Advocate initiated a telehealth program to provide behavioral health services via computer technology at sites where psychiatrists and/or psychologists are unavailable or present only on a limited basis. Behavioral health providers are located at one of Advocate’s hospitals and provide telehealth services to

107 Hospital stays

BEHAVIORAL AND USE (ED) visits HEALTH CONDITIONS Rate per Rate per 1,000 population OF THE ED IN HIGH-NEED ADULTS 1,000 population

Emergency department (ED) use is higher for high-need adults with a behavioral health condition.

ED visits Rate per 1,000 population

107

551 Stays for high-need adults with a behavioral health condition

513 Stays for high-need adults without a behavioral health condition

Visits for high-need adults with a behavioral health condition

183

538 Visits for high-need adults without a behavioral health condition

Total adult population

683

Hospital stays Rate per 1,000 population

Source: Courtesy of The Commonwealth Fund. Used with permission. Based on data from the 2009-11 Medical Expenditure Panel Survey as analyzed by C.A. Salzberg, Johns Hopkins University.

LEADERSHIP  July 2017

Adler says.183 One study, published in 2008 in the American Journal of Managed Care, reported that the 107 IMPACT (Improving Mood and Promoting Access to Collaborative Treatment) model usedHospital to treatstays depression Emergency department in older adults suggested an ROI of up to 6:1per in savings.3 (ED) visits Rate Advocate Health Care, a Downers Grove, Ill.-based Rate per 1,000 population 1,000 population 12-hospital system with a large physician network, has integrated behavioral care in both the inpatient and outTotal adult population patient settings. In 2013, Advocate created a behavioral High-need adults without behavioral health service line to address health conditionthe needs of patients with behavioral and High-need chronic medical conditions, an estimated adults with behavioral 26 percent of itshealth patient population, says Jeannine condition Herbst, executive director of Advocate’s Behavioral Health Service Line The program includes automatic screening for depression and anxiety683 for patients who are in the ED and inpatient medical units and are 65 and older. Patients who score above a certain threshold then receive treatment from a psychologist or psychiatrist. 551 538 On the outpatient side, patients are screened 513 annually for depression and anxiety during primary care visits. Advocate also developed a collaborative care program at two physician practice sites that have large numbers of high-risk patients with behavioral and chronic conditions. Patients are treated for their behavioral health condition by an embedded psychologist who spends time at both clinics, consults on patient cases with a psychiatrist, and provides suggestions to

8 LEADERSHIP  HFMA.ORG/LEADERSHIP

“If you are talking about a healthcare system that is going to effectively manage the entirety of medical costs, you cannot ignore substance abuse disorders and behavioral health conditions.” — David Kemp, MD, Behavioral Health Service Line, Advocate Health Care

six other hospital sites and two physician practice sites in the system. Advocate plans to expand the collaborative care model to other practice sites through telehealth technology. The hub of providers also offers curbside consults to primary care physicians to assist them with the management of their patients. “We’re building our future model on the telehealth platform because we know there’s a shortage of providers, as well as a need to treat a large number of patients in many physician practices, and it’s more cost-effective to do this virtually than it is to embed providers in every office,” Herbst says. Another key component of the program is care management. Advocate’s care managers are part of the team and manage complex patients. Advocate recently has invested in training medical care managers in integrated care management and is working on expanding the curbside consult service to them. Advocate’s behavioral health service line providers also participate in a virtual interdisciplinary care team with physicians, a pharmacist, care managers, and postacute providers to optimize care coordination and provide resources for patients. OFFSETTING MEDICAL COSTS “The main reason the behavioral health service line was started was to support our population health efforts by reducing the total cost of medical care by addressing the behavioral health comorbidity of our patients in our full-risk plans,” Herbst says. “But it is part of our mission to treat the whole person, so we provide services such as the screening and the telehealth access to psychiatrists and psychologists to all of our other patients.” From the beginning, the belief was that expenses for behavioral health services would be offset by expected savings in the total cost of care, Herbst says. New payment structures, such as the CMS collaborative care codes, are encouraging, but in general reimbursement for this type of model is still being developed by payers, she says. Because some of Advocate’s programs, such as collaborative care and telehealth, are fairly new, there is not enough data to make a final judgment on whether

the organization’s behavioral health efforts are providing sustainable cost reductions. But directionally, the data looks promising, Herbst says. One metric Advocate started tracking, in 2013, was the variable direct cost of a hospital stay. Initially, Advocate found that patients with a chronic medical condition and behavioral condition had higher costs of care, Kemp says. “And some of the national data will demonstrate that the cost is anywhere from two to four times higher when a behavioral health condition is present,” he says. For 2015 and 2016, with the inpatient integrated behavioral health program having been implemented at the end of 2014, Advocate found that the cost gap between chronic medical patients with and without a behavioral condition was shrinking. In some instances, the cost of care was actually lower for someone with a behavioral and medical David Kemp, MD, medical condition. director, Advocate Other services, while Behavioral Health very much value-based, Service Line largely are not yet reimbursed. With telehealth services, for example, payment varies by state, and many payers still do not cover the service, Kemp says. “But to be effective for population health, and to be efficient, we need to start using those types of technology more often, and we’re hoping to see payers getting behind that and supporting those types of interventions,” he says. WHAT’S NEXT? For the most part, providers and health plans are encouraged by the new emphasis on behavioral care. But will that optimism soon fade? Amid progress in behavioral care and value-based models, there is political uncertainty over the continuation of the healthcare reform efforts of the past several years and how potential changes will affect care and coverage. The consensus among these providers and plans is that reversing course is not an option. The question is no longer whether integrated care will reduce total costs but instead how to integrate behavioral care in a way that reduces costs most dramatically. “If you’re talking about a healthcare system that is going to effectively manage the entirety of medical costs, you cannot ignore substance abuse disorders and behavioral health conditions,” Kemp says. “It’s just too big and too much of a player to go unaddressed.” Karen Wagner is a freelance healthcare writer based in Forest Lake, Ill., and a frequent contributor to HFMA publications ([email protected]).

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([email protected]); Jeffrey Weilburg, MD, medical director, Massachusetts General Physicians Organization, Boston ([email protected]). FOOTNOTES: 1. Donaldson, M.S., Yordy, K.D., Lohr, K.N., et al., “Primary Care: America’s Health in a New Era,” Institute of Medicine, 1996. 2. Hayes, S.L., McCarthy, D., and Radley, D., “The Impact of a Behavioral Health Condition on High-Need Adults,” The Commonwealth Fund, Nov. 22, 2016. 3. Unutzer, J., Katon, W.J., Fan, M-Y, et al., “Long-Term Cost Effects of Collaborative Care for Late-Life Depression,” American Journal of Managed Care, February 2008.

DATA CENTER PERCENTAGE OF PEOPLE WITH A USUAL PLACE TO GO FOR MEDICAL CARE IN 2016 People ages 18 to 24 and 25 to 44 were least likely to have a usual place to go for medical care. Children under age 18 were more likely than adults ages 18 to 64 to have a usual place to go for medical care. For both men and women older than 25, the percentage with a usual place to go for medical care increased with age. 100

Total

Male

Female

95% confidence interval

90

80

70

60

50

40 All ages

Under 18

18–24

25–44

45–64

65 and over

Age group (years) Notes: Data are based on household interviews of a sample of the civilian noninstitutionalized population. Usual place to go for medical care does not include a hospital emergency department. The analyses excluded the 0.7 percent of people with an unknown usual place to go for medical care. Source: Clarke T.C., Norris T., Schiller J.S., “Early release of selected estimates based on data from 2016 National Health Interview Survey,” National Center for Health Statistics, May 2017 (http://www.cdc.gov/nchs/nhis.htm).

LEADERSHIP  July 2017

Interviewed for this article: Deb Adler, executive vice president for network strategy, Optum (deborah.adler@ optum.com); Patrick Gordon, associated vice president, Rocky Mountain Health Plans (patrick.gordon@rmhp. org); Jeannine Herbst, executive director, Behavioral Health Service Line, Advocate Health Care, Downers Grove, Ill. ([email protected]); David Kemp, MD, medical director, Behavioral Health Service Line, Advocate Health Care, Downers Grove, Ill. (david. [email protected]); Beth Kohler, deputy director, Arizona Health Care Cost Containment System

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ROUNDTABLE

LEADERSHIP  HFMA.ORG/LEADERSHIP

INTEGRATING BEHAVIORAL HEALTH CARE AND PRIMARY CARE In the Healthcare Challenge Roundtable, healthcare finance, clinical, and health plan leaders discuss ways to collaborate on solutions to some of the industry’s biggest issues. This month’s topic: integrated behavioral health care. By Kathleen Vega According to the National Institute of Mental Health, mental disorders affect tens of millions of Americans each year, and only about half of those individuals receive treatment. One barrier is the lack of reliable mechanisms in healthcare settings that ensure patients connect with mental health services. As the industry aims to deliver higher-quality care at a lower cost, healthcare providers are recognizing the need to better integrate behavioral health care with primary care to make sure all patients get the treatments they require to sustain long-term health outcomes. In this edition of the Healthcare Challenge Roundtable, senior provider and health plan leaders examine strategies for achieving such integration. Participating are Michael Alwell, vice president, revenue cycle for RWJBarnabas Health, West Orange, N.J.; Michael Plopper, MD, chief medical officer, Sharp Behavioral Health Services, San Diego; and Hyong Un, MD, chief psychiatric officer, Aetna. Why is it important to integrate behavioral care with primary care? Hyong Un: First, most people seek treatment for a mental health condition in the primary care setting because their primary care doctor is usually their most trusted physician. Although many behavioral health issues can be successfully managed as part of primary care, it is helpful to have behavioral health resources—

Michael Alwell RWJBarnabas Health

Michael Plopper, MD Sharp Behavioral Health Services

psychiatrists, therapists, counselors, social workers, and so on—readily available should the patient’s problem surpass the primary care physician’s abilities. In addition, chronic medical disorders—including coronary artery disease, diabetes, and musculoskeletal issues—regularly have a behavioral health component. In many cases, there will be depression associated with these disorders, which can impact patients’ abilities to adhere to medication regimens and self-manage their conditions. It is crucial that organizations be aware of and treat the underlying behavioral alterations of physical comorbidities. Overall, assimilating behavioral health into primary care is important to maintain the health of a patient population. Especially as organizations take on responsibility for more-holistic patient care that emphasizes value, they are starting to appreciate the criticality of behavioral health resources. Let’s face it, you can’t manage chronic illness, limit unnecessary emergency room visits, and reduce avoidable readmissions without these kinds of resources. Michael Alwell: When behavioral health care and primary care are integrated, primary care physicians can quickly refer patients to the appropriate behavioral health practitioners to meet the patients’ needs. Not only does this approach ensure that patients receive the level of care they require, but it also avoids placing the primary care providers in a position where they must address a condition that might be outside of their comfort zone. Also, if you can bring both types of care into a single practice location, it saves time on the billing side because you may not need to obtain additional authorizations and potentially refer the patient outside of the network.

Hyong Un, MD Aetna

11

Michael Plopper: The coordination of behavioral health care and primary care has been an underdeveloped component of healthcare delivery in the United States for a long time. Although providers have talked about the need for integration for at least 20 years, the country is not at a place where it could say it has accomplished this goal—other than in a few locations. Oftentimes communication is quite poor between mental health and primary health delivery systems. The traditional siloed care models have led to subpar interactions and missed opportunities. Due to the stigma associated with mental health, the dearth of payment mechanisms for these types of services, and psychosocial factors such as lack of transportation and family support, patients who are seriously ill— and even those with less severe illnesses—can struggle to receive appropriate and adequate mental health care. Un: Behavioral health specialists and primary care physicians approach patient diagnosis and care differently, and this has historically presented some roadblocks to integration. For example, primary care physicians tend to see patients at a fairly rapid rate, and weaving behavioral health into the primary care office workflow could be problematic, particularly if the behavioral healthcare delivery model follows traditional behavioral health workflows. Therapists are accustomed to seeing their patients for 30 minutes to an hour, and that may or may not work in a primary care setting where doctors see patients every 10 to 15 minutes. There have also been issues around financing. For the longest time, behavioral health was carved out as separate from the rest of a person’s medical health benefits. In fact, Aetna was one of the first companies to integrate behavioral health and medical health and have the financing come from one source. Not every payer takes this approach, and that can add complications to the behavioral health-primary care dynamic. Ultimately, bringing behavioral health and primary health together requires marrying two different delivery systems and two different financing systems. That coupled with the variations in practice style and workflow makes integration challenging. Things are starting to change, but it’s going to take a while. Alwell: Another barrier has been the reluctance of some behavioral health providers to participate in managed care networks. Historically, the payment rates tied to these networks have been quite low for behavioral health professionals. To overcome this issue, some large hospitals and health systems, like RWJBarnabas, are employing behavioral health professionals, enrolling them into various managed care plans and placing them in offices side by side with primary care providers—thereby improving access for patients who need the services.

That said, it becomes quite costly for healthcare organizations to employ these providers. However, we view it as part of a much larger primary care strategy that encompasses this kind of care. What are some benchmarks for assessing the effectiveness of integrated care efforts? Un: I think organizations should look at three different metric domains: structure, process, and outcomes measures. Structurally, you must have behavioral health resources that are available for integration—enough psychiatrists, therapists, care managers, and so on. You also need the ability to create and manage a registry. Once you have a sense of the structure, then make sure you’re following solid processes. Are you consistently screening for mental illness, such as depression? Are you referring those patients who screen positive to a mental health provider? Is there two-way communication between the primary care office and the mental health provider? In addition to process measures, study patient outcomes. For patients with depression, does their average depression score decrease? Are suicide rates dropping? Are there fewer emergency room visits? Finally, review patient satisfaction scores for patients with a diagnosed mental illness. Do they feel their needs were addressed? Were providers compassionate? Alwell: The integration of behavioral care and primary care should result in a reduction in emergency department (ED) visits and reduced psychiatric admissions. Through integration, providers may be able to monitor whether patients are compliant with their medications for both the mental illness and any chronic conditions. If the behavioral health issues are not being managed properly, there’s a good possibility the patients aren’t going to be compliant with any of their medication regimens and will end up back in the hospital or ED for medical conditions in addition to behavioral health problems. Plopper: Another metric to examine is follow-up after initial screening. Right now, primary care offices are starting to effectively screen for conditions such as depression. However, it would be smart to look at what happens after these patients are screened and found to have depression or another mental illness. Are they provided services? Are they referred to a specialist? Are they compliant with medication? Is there improved attention once the disorder is identified? It also might be beneficial to study severe negative outcomes, such as suicide rates or hospitalizations for mental illness. The literature supports the notion that patients who commit suicide have sometimes seen a primary care doctor in the recent past. There’s an opportunity to better provide services for people who are ill and contemplating this drastic act. Similarly, some hospitalizations could be avoided if patients were better served on an outpatient basis.

LEADERSHIP  July 2017

Why has the integration of primary care and behavioral health care been difficult historically?

12 LEADERSHIP  HFMA.ORG/LEADERSHIP

Which established models are effective at promoting high-quality integrated care? Plopper: Even though the industry has been talking about integration for 20 years, there aren’t many great models out there. One that is effective is called the Collaborative Care Model and emerged from Dr. Jurgen Unutzer at the University of Washington. It’s moderately robust and has been in place for a number of years, demonstrating improved outcomes and care quality at lower costs. The model mostly involves ready access for primary care offices to psychiatric consultation—either in person or through telemedicine. Un: The University of Washington model is probably the best one. There are numerous quality studies that indicate it works. To be effective, an integrated program must have care management, registry use, and measurement-driven care, and Dr. Unutzer’s model has all those components. Alwell: At RWJBarnabas Health, we are working on a program in which we will place a psychiatric advanced practice nurse (APN) in a primary care physician’s office. The primary care provider will screen for depression and other cognitive impairments and refer any patients who screen positive to the APN, who can further assess the patient’s cognitive needs or behavioral issues and prescribe therapy or medications as appropriate. Because the APN is located on site, we believe there will be greater interaction between primary care and behavioral health. Are you seeing more examples of constructive collaboration between providers and health plans? Plopper: Most of the models I’ve worked with are selffunded or funded through grants. For integration to take hold, it is going to require global payment policies in which payers and providers are accountable for the total cost of care and patient outcomes. I think there should be a stronger effort by public-sector payers to lead the way. As healthcare systems, we have many different masters in terms of our payment sources, and that can

ROUNDTABLE ARCHIVE Check out previous installments of the Healthcare Challenge Roundtable: Assessing the Value of Care hfma.org/Leadership/ValueAssessment Optimizing the Preauthorization Process hfma.org/Leadership/Preauthorization Working Together to Make APMs Succeed hfma.org/Leadership/APMs

lead to complexity and confusion. The more we can come together and break down barriers, the more we can make some meaningful change. Alwell: We are in discussions with one of the largest payers in New Jersey about integrating behavioral health and primary care, looking to increase the referrals from primary care to behavioral health and streamline that process. For many health plans, an important first step should be finding ways to incentivize primary care to refer patients for early screening by behavioral health professionals. Some of these primary care physicians are afraid to refer out of their practice for fear of being penalized by the insurance plan for overutilization of resources. With an integrated system, the referral and initial treatment could reside within the practice if the plan allowed the primary care physician to have an APN or other psychiatric professional within the practice. Another step would be to break down the silos between reimbursement channels. A number of payers still carve out patients’ behavioral health benefits from their medical benefits, and that separation often causes confusion for both patients and providers, sometimes resulting in delays in treatment. Un: I’ve been at this for 15 years, and I think in the past three to four, things have really started to move forward. The Centers for Medicare & Medicaid Services just approved a set of codes related to collaboration and integration, and they are also more focused on care management. The American Psychiatric Association has a large project to retrain psychiatrists in a model that is more collaborative. Much of the improvement we’ve seen so far has stemmed from different organizations realizing that behavioral health is essential to value-based contracting. With that and a shortage of psychiatrists, organizations are beginning to understand the benefits of offering some level of behavioral health care in the primary care setting. There always will be a need for specialist psychiatrists. We have seriously ill patients with mental health conditions who will need to be managed by a psychiatrist, but there’s a sizable number of patients who through a collaborative care model can be monitored without having to see a psychiatrist because they can be managed successfully in the primary care setting. Kathleen Vega is an HFMA contributing writer and editor ([email protected]). Interviewed for this article: Michael Alwell, vice president, revenue cycle, RWJBarnabas Health, West Orange, N.J. ([email protected]); Michael Plopper, MD, chief medical officer, Sharp Behavioral Health Services, San Diego ([email protected]); Hyong Un, MD, chief psychiatric officer, Aetna ([email protected]).

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The Agency for Healthcare Research and Quality established this framework, which shows 10 functional domains for integrated behavioral care and associated measurement constructs. The measurement constructs describe specific structures (i.e., characteristics), processes (i.e., actions), and outcomes that can be observed during integrated behavioral care. For a full list of measures for each domain, see AHRQ's Atlas of Integrated Behavioral Health Care Quality Measures.

1

CARE TEAM EXPERTISE

2

CLINICAL WORKFLOW

The team is tailored to the needs of patients and populations, with a suitable range of expertise and roles.

The team uses shared operations, workflows, and protocols to facilitate collaboration.

STRUCTURE Healthcare professionals with a range of expertise and roles are available and can be tailored into a team to meet the needs of specific patients and populations.

STRUCTURE Clinical protocols and workflows are clearly documented. This implies that the protocols and workflows specify: • The roles, functions, and activities of all team members within the shared workflows • The types of information that need to be shared • The standard way to manage the addition of team members and transitions

3

4

PATIENT IDENTIFICATION

PATIENT & FAMILY ENGAGEMENT

The team employs systematic methods to identify and prioritize individuals in need of integrated care.

The team engages patients and family (as appropriate) as active members in the integrated care team and in shared care plans.

PROCESS Screening or other case-identification processes are used to identify and prioritize people who need integrated behavioral health care in a timely manner.

STRUCTURE Protocols or workflows for patient and family engagement are documented for care teams and in care plans.

5

6

TREATMENT MONITORING

The team systematically measures patient outcomes over time and adjusts treatment as needed. STRUCTURE Clinical information (registry, outreach, other information) is readily available for monitoring and adjusting treatment. A follow-up system (with detail on components) and workflows to use the system are documented.

7

OPERATIONAL RELIABILITY

The team is supported by reliable and robust office processes. PROCESS integrated behavioral health care to support highly reliable operations. Employ quality-improvement approaches, such as Lean or other process

9

DATA COLLECTION & USE

The team is supported by the collection and use of practice-level data to achieve high-quality, high-value care. STRUCTURE Practice-wide systems to collect and use data for data-driven quality improvement are expected and present.

LEADERSHIP ALIGNMENT

The team is supported by leadership and administrative alignment. PROCESS Allocate resources in a manner that is consistent with stated priorities for integrated care. Identify and address practical conflicts with other organizational priorities, incentives, and habits.

8

BUSINESS MODEL SUSTAINABILITY

The team is supported by a sustainable business model. STRUCTURE A business model that is sustainable for the practice, its providers, and its patients is appointments, and driving and transportation costs in time and money—as well as insurance premiums.

10

DESIRED OUTCOMES

Patient experience measures.a OUTCOMES Individual patient experience with integrated behavioral health care. Aggregated patient experience for the panel of patients who receive health care. Aggregated patient experience for population denominators defined by the practice.

Footnote: a. Provider experience, clinical outcomes, financial outcomes, and system experience are expected to be included in the outcomes domain in a future edition of the AHRQ’s IBHC Atlas, from which this framework was referenced. Source: Korsen, N., Narayanan, V., Mercincavage, L., et al., Atlas of Integrated Behavioral Health Care Quality Measures, Agency for Healthcare Research and Quality, Rockville, Md., June 2013. AHRQ Publication No. 13-IP002-EF (https://integrationacademy.ahrq.gov/resources/ibhc-measures-atlas).

®

LEADERSHIP  July 2017

A FRAMEWORK FOR INTEGRATED BEHAVIORAL HEALTH CARE

CONSUMERISM

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VIRTUAL VISITS COME OF AGE Consumers have come to appreciate virtual visits conducted over their computers, tablets, or smartphones. Insurers and providers are warming to them. Now comes the hard part. By Lola Butcher

Partners Connected Health

Following a path taken by many other provider organizations, Beacon Health System, a two-hospital system serving northern Indiana and southern Michigan, introduced real-time outpatient video visits at the beginning of this year. The organization was late to the virtual-visit movement—until last year, Indiana law placed onerous restrictions on telehealth—but was more than ready to jump in.

A patient participates in a virtual visit via video. Beacon Connected Care allows patients to connect with physicians online via smartphones, tablets, or computers. Consumers appreciate the convenient service, says Lori Turner, chief marketing, experience and innovation officer. And she expects it will lower the cost of delivering care, improve patient outcomes, and boost physician satisfaction with their jobs. “The opportunities for this kind of platform really can alter the trajectory of how you run your business,” she says. “We’re not just looking at it for incremental improvements.” For several years, some Beacon patients have benefited from telehealth’s most obvious attribute: expanded access to care. The system has offered telestroke consults in its emergency departments, dramatically improving the care available to stroke patients; and tele-psychiatry, providing hard-to-find counseling services to patients who come to a medical office for video appointments with remote physicians.

In January, Beacon introduced virtual urgent-care visits directly to consumers and employers, allowing minor symptoms to be checked out via an online session that, on average, lasts just over six minutes. “We actually offer it to our 7,000 Beacon Health employees as part of their benefit program,” Turner says. “And we’ve had high levels of early adoption.” But Turner is more excited about what she foresees as a new way of caring for patients with chronic conditions. To test the waters, a group of 10 physicians is beginning to schedule follow-up visits via telehealth. That makes life easier for patients who don’t have to travel and improves a practice’s efficiency. “Every time you room a patient, it takes staff to do that,” Turner says. “This will save time and cost, and we are looking at it as an opportunity to do a better job serving our chronic care patients.” Beyond that, Turner believes telehealth will be the technology that finally makes physicians’ work lives easier. While the implementation of electronic health record technology has decreased physician productivity, technology that supports virtual visits allows physicians to see more patients in less time. Physicians’ reception to technology-supported visits was mixed initially, but enthusiasm is building as they learn how much patients like it. “We’re getting great feedback from our customers,” Turner says, referring to the 5-star rating system embedded into the virtual care platform. “We’re running at 4.8 stars in terms of how they rate the experience and the provider.” Beacon Health is ramping up to offer inpatient dermatology and psychiatric consults via telehealth—and encouraging physicians to take the lead on how virtual care evolves. Some physicians want to offer telehealth appointments on Saturdays to reduce the crush of patients clogging the waiting room on Monday mornings. Others Lori Turner, chief want to use it to connect marketing, experience with nursing and innovation officer, home patients. Beacon Health System

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CHANGE BRINGS CHALLENGES Beacon Health’s enthusiasm about the potential of outpatient care delivered via virtual visits is widely shared. Although such services are becoming commonplace, however, challenges remain, says Joseph Kvedar, MD, vice president of Connected Health at Partners HealthCare in Boston. While virtual care has been in limited use for many years, its broad adoption is still new, and best practices have not yet been determined. Among the issues to be sorted out: Payment. For years, payers’ refusal to pay for most types of telehealth visits limited the service’s growth. That is changing as employers demand access to virtual care for workers and their dependents. “And since the insurance industry feels this is needed, they are of course compensating for it,” Kvedar says. But that compensation has caveats. Many insurers have their own relationships with virtual care companies, and payment is available only to providers that are affiliated with those companies. For example, Cigna includes two companies—American Well and MD Live— as in-network providers. Physicians who provide telehealth access but are not affiliated with one of those companies are considered out-of-network for coverage purposes, according to Cigna spokesman Joe Mondy. Fragmentation of care. Most provider organizations that offer virtual visits are affiliated with a company that provides the technology platform, and coverage when the organization’s clinicians are not available. While some virtual visit programs create seamless records, that is not a universal practice. Rather, when patients are seen by one of the vendor’s providers, as opposed to their regular provider or a colleague within the health system, records of the visit may not flow to their primary care physician. “They might remember to get you a copy for your primary care doc, but they may not,” Kvedar says. “That sets up a completely parallel record system, and it is a challenge.” Quality of care. As health systems seek to standardize care, the use of virtual-care clinicians employed by telehealth companies may introduce a complicating factor. When researchers compared the performance of Teladoc and physician offices on Healthcare Effectiveness Data and Information Set (HEDIS) measures, they found the Teladoc providers were less likely to order appropriate diagnostic tests and had poorer performance on antibiotic prescribing for bronchitis.1

Separately, a study using fake patients to assess direct-to-consumer tele-dermatology websites identified problems including incorrect diagnoses, treatment recommendations that contradicted guidelines, and prescriptions made without disclosing possible adverse risks.2 Utilization patterns. Joseph Kvedar, MD, vice When researchers president of Connected reviewed claims data for Health, Partners enrollees in an HMO who HealthCare sought telehealth treatment for acute respiratory infections, they found that net annual spending on those conditions increased by $45 per user. While 12 percent of the telehealth visits replaced visits to other providers, 88 percent represented new utilization.3 GROWING FORWARD Despite the challenges, the benefits of virtual care are expected to support its continued growth, Kvedar says. As risk-oriented payer contracts gain traction, provider organizations need to improve patients’ access to care so that they stay healthy, and focus on efficiency to keep care delivery costs as low as possible. At Massachusetts General Hospital, where Kvedar practices dermatology, about 25 percent of patient service revenue flows through risk-based contracts, prompting considerable investment in population health strategies that include video visits. “Mass General did several thousand of these various electronic interactions last year, and it is felt that there was efficiency gained and a real avoidance of high-cost care in certain areas,” he says. “This is clearly the tip of a spear of innovation where you start to see care that is only in-person when it really needs to be.” Lola Butcher writes about healthcare business and policy topics for several HFMA publications (lola@ lolabutcher.com). Interviewed for this article: Joseph Kvedar, MD, vice president of Connected Health, Partners HealthCare, Boston; Lori Turner, chief marketing, experience and innovation officer, Beacon Health System, South Bend, Ind. FOOTNOTES: 1. Uscher-Pines, L., Mulcahy, A., Cowling, D., et al., “Access and Quality of Care in Direct-to-Consumer Telemedicine,” Telemedicine and e-Health, April 2016. 2. Resneck Jr., J.S., Abrouk, M., and Steuer, M., “Choice, Transparency, Coordination, and Quality Among Direct-to-Consumer Telemedicine Websites and Apps Treating Skin Disease,” JAMA Dermatology, July 2016. 3. Ashwood, J.S., Mehrotra, A., Cowling, D., et al., “Direct-To-Consumer Telehealth May Increase Access To Care But Does Not Decrease Spending,” Health Affairs, March 2017.

LEADERSHIP  July 2017

“In terms of clinical delivery and when it’s appropriate to use it, that’s a physician-led conversation,” Turner says. “This has huge ability to be transformative to our entire organization in terms of how we think about care delivery.”

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INNOVATION

LEADERSHIP  HFMA.ORG/LEADERSHIP

THE NEW KNOWLEDGE MATCHMAKER Artificial intelligence is helping providers match patients to clinical trials and offering treatment recommendations to specialists. What does the next round hold? By Laura Ramos Hegwer Physicians know that when patients come to the emergency department complaining of “pressure” in their chest, it could be a sign of chest pain caused by myocardial infarction. But getting an artificial intelligence (AI) platform that can “read” notes in an electronic health record to understand that “pressure” in this case means chest pain rather than hypertension (i.e., “blood pressure”) requires collaboration between data scientists, computer scientists, and clinicians. Paul Tang, MD, vice president and chief health transformation officer at IBM Watson Health, believes that with proper training from humans, AI platforms can provide clinicians with better access to evidence-based treatment recommendations tailored for a specific patient. “Only 15 percent of the decisions that clinicians make are supported by evidence from randomized controlled trials,” Tang says. Even when such evidence exists, it is often based on data from fairly homogeneous populations. “But AI applications can help provide personalized health care that takes into account a more holistic view of an individual beyond their demographics to include socioeconomic status, education, and preferences, which can affect treatment compliance and outcomes,” he says. Specifically, AI applications can create precision cohorts that allow clinicians to review treatment outcomes in specific population subsets that share the same characteristics as their patients.

“AI applications can help provide personalized health care that takes into account a more holistic view of an individual beyond their demographics to include socioeconomic status, education, and preferences.” —Paul Tang, MD, IBM Watson Health

KNOWLEDGE MATCHMAKING The latest AI technology offers clinical options in what can be described as a type of knowledge matchmaking, in which the platform pairs the most relevant evidence with individual patients based on their clinical and life context. “The ability for a human to do that kind of matchmaking is fairly limited,” Tang says. “So what we are asking the machine to do is to narrow the search space and try to find the best match given our knowledge of this particular individual, and present those options to the human professional, who makes the judgment and comes up with a relevant treatment plan. “This is not about replacing an individual but rather offloading the data preparation and assimilation to a machine and, in a sense, offering complementary or augmented intelligence.” Today’s AI platform can organize vast amounts of data from medical literature and other sources into “knowledge graphs,” which connect related concepts (for example, a disease would be connected to a symptom, which would be connected to a treatment). This process requires a unique kind of training using machine-learning approaches. Scientists might interview an expert such as an oncologist, who can describe ideal treatments for specific conditions or review and annotate the platform’s treatment recommendations with correct answers. They also may incorporate unsupervised, continuous-learning approaches that capture when users accept or ignore the recommendations, which helps the AI platform make better suggestions in the future. “Underpinning all of this is a constant review and assessment of the quality of the feedback,” says Eric W. Brown, PhD, director of foundational innovation at IBM Watson Health. “You want experts to be correcting the system, and you want to validate that the training data you are using is accurate, comprehensive, and effective.” APPLICATIONS FOR CANCER One of the latest AI applications for oncology was trained by subspecialists at New York City’s Memorial Sloan Kettering (MSK) Cancer Center who worked alongside computer scientists and project managers. The team used National Comprehensive Cancer Network guidelines to teach the system the universe of possible treatment options. MSK cancer subspecialists then prioritized the options into recommendations.

17 LEADERSHIP  July 2017

For each cancer type, the subspecialists identified hundreds of cases from MSK that included every clinical attribute they believed was important to help a clinician make the right decision. These cases also included what the subspecialists determined was the right “answer” to a clinician’s question. For example, subspecialists described how they would treat a patient with metastatic lung cancer who is a certain age, has a specific previous treatment history and specific lab results, and is taking certain medications. From there, the system “learned” that those attributes pointed to a given answer, or treatment recommendation. This process was repeated hundreds of times to ensure the system can ultimately learn what weight to give each patient attribute when recommending a therapy. Over time, the system becomes better and better at mimicking the thought process of the human expert. In a blog post, Mark Kris, MD, a medical oncologist who leads the training project at MSK, discussed the potential healthcare applications of AI. “Doctors treating these illnesses now know how different they are from person to person,” he wrote. “We need better ways to help us understand the complexity and variation of these diseases to improve care and research. Textbook and guideline-based treatments are a good place to start, but they can’t address the many biological and other factors affecting the course and aggressiveness of cancers.” AI systems also can be trained to search their body of knowledge for evidence such as American Society of Clinical Oncology (ASCO) guidelines, textbook information, and peer-reviewed literature to support their recommendations. AI platforms with natural-language processing abilities also have applications for clinical trial matching. A feasibility study presented at an ASCO conference found that an AI platform cut the time required to screen patients for clinical trial eligibility by 78 percent. During the pilot, the platform “read” the clinical trial protocols at one large Arkansas medical practice and evaluated data from patient records and clinical notes to automatically exclude ineligible patients from the pool.

Mark Kris, medical oncologist, Memorial Sloan Kettering Cancer Center Such clinical-trial matching technology has been used the longest at Mayo Clinic, notes Andrew Norden, MD, MPH, MBA, deputy chief health officer for oncology and genomics at IBM Watson Health. Preliminary data from Mayo demonstrate improvement of more than 50 percent in the breast cancer trial accrual rate from 2015 to present day. Laura Ramos Hegwer is a freelance writer and editor based in Lake Bluff, Ill. ([email protected]). Interviewed for this article: Eric W. Brown, PhD, director of foundational innovation, IBM Watson Health, Yorktown Heights, N.Y.; Andrew Norden, MD, MPH, MBA, deputy chief health officer for oncology and genomics, IBM Watson Health, Cambridge, Mass.; Paul Tang, MD, vice president and chief health transformation officer, IBM Watson Health, Cambridge, Mass. (kristi. [email protected]). This article is based in part on a presentation at the American College of Healthcare Executives 2017 Congress on Healthcare Leadership in Chicago.

INNOVATION IN PRICE TRANSPARENCY This article was excerpted from a Leadership digital exclusive. For much more, see hfma.org/Leadership/ PriceTransparency. Showing patients how costs vary by provider and facility may not be enough to improve value across the board. But coupling new benefit and network design with enhanced price transparency tools has the potential to change consumer behavior. James C. Robinson, PhD, MPH, professor of health economics at the University of California, Berkeley, believes reference-based benefit design, also known as

reference pricing, can promote greater cost consciousness among healthcare consumers. Reference prices set a maximum allowable cost per service, with the patient assuming responsibility for the difference between what the plan will pay and what the provider charges. The issue with traditional, deductible-centered coverage is that most consumers are not paying the “last dollar,” Robinson says. “Reference pricing creates an incentive for people to care.” Reference-based benefit designs provide good coverage if patients choose lower-cost providers, Robinson says, making them preferable to high-deductible plans.

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POLICY

LEADERSHIP  HFMA.ORG/LEADERSHIP

OBSTACLES REMAIN FOR TEAM-BASED CARE Some allied health professionals see state laws as the biggest hindrance. By Rich Daly The growing use of team-based care continues to run into legal and regulatory hurdles, industry advocates say. Shawn Martin, senior vice president at the American Association of Family Physicians, noted that health care—particularly primary care—is moving toward a team-based care approach and payment model. “The transformation is taking hold, but there are regulations that prohibit teams from functioning at the highest level possible,” Martin said in May at a healthcare policy discussion in Washington, D.C. Among the obstacles to team-based care are the Stark Law, which prohibits physician self-referral, and other regulations. Hospitals have targeted the same obstacles. The American Hospital Association (AHA) said organizations cannot succeed in their efforts to coordinate care and participate in new payment models because of such “outdated” regulations. As part of the Trump administration’s promised rollback of redundant and outdated regulations, AHA in December wrote the incoming administration to urge creation of a new exception “that protects any arrangement that meets the terms of a newly created Anti-Kickback safe harbor for clinical integration arrangements.” SCOPE-OF-PRACTICE CONCERNS Some allied health professionals see a bigger obstacle in state laws. Cindy Cooke, president of the American Association of Nurse Practitioners, cited state licensure laws on scope of practice for not keeping “pace with the education and expertise of everyone at the table.” “There’s a cost with collaborative agreements or supervisory agreements that actually drive up the cost of health care,” Cooke said, referring to physician oversight requirements in 28 states. “In many instances, nurse practitioners are paying physicians a great sum of money in order to provide that collaborative or supervisory piece of paper.” Other costs imposed by such restrictions, she said, include reduced access to care in rural and urban areas This article originally ran as part of HFMA’s daily news coverage. For much more on the latest developments in healthcare business and finance, see hfma.org/news.

and reduced ability to provide the goods and services that keep patients from progressing to costly inpatient care. Furthermore, state scope-of-practice requirements are echoed in many physician-centric Medicare rules. “Right now, I can’t order diabetic shoes, again because of these Medicare statutes,” Cooke said. “Because once the physician writes the prescription for their diabetic shoes, they actually have to assume the care of that diabetes, according to law.” Ben Ippolito, a healthcare economist at the American Enterprise Institute, questioned whether the potential of scope-of-practice changes to reduce costs is overstated. Research indicates scope-of-practice expansions have “modestly” lowered prices for services like well-family or well-child visits. But such changes do not lower total spending. “The problem is the price may go down, the quantity may go up,” Ippolito said. “So we have better access, which is kind of a nice way of saying utilization goes up. And so it’s not necessarily true that cost is going to be lower on net.” TEAM COSTS Fitch Ratings warned not-for-profit hospitals in April that improvement in the labor market is raising the demand for nurses and advanced practitioners, resulting in higher salary and benefits costs. Cooke agreed that utilization may increase with the greater access to care that comes with expanded scope of practice. But for patients with diabetes, for example, increased primary care access can reduce costly progression to amputation, diabetic retinopathy, or kidney disease. “We really can see the outcomes when we have that,” Cooke said. Martin urged letting state legislatures remain the arbiters of scope of practice. “State legislatures in general should take very seriously their obligation to ensure appropriate access to health care for their citizens and identify policies that promulgate the distribution of healthcare professionals of all types in all communities,” Martin said. Martin also noted that various expansions of scope of practice, also known as open-practice laws, have not made an impact on federally designated health professional shortage areas or other population groups experiencing a shortage of providers.

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Full Practice State practice and licensure law provides for nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, and initiate and manage treatments—including prescribing medications—under the exclusive licensure authority of the state board of nursing. Reduced Practice State practice and licensure law reduces the ability of nurse practitioners to engage in at least one element of NP practice. State requires a regulated collaborative agreement with an outside health discipline for the NP to provide patient care or limits the setting or scope of one or more elements of NP practice. Restricted Practice State practice and licensure law restricts the ability of a nurse practitioner to engage in at least one element of NP practice. State requires supervision, delegation, or team management by an outside health discipline for the NP to provide patient care. Source: State nurse practice acts and administration rules, 2017. Compiled by the American Association of Nurse Practitioners. Used with permission.

“I cringe a little bit about saying, ‘We’re going to do X, and then all these people are going to go out in these rural counties because history and statistics just demonstrate that,’” Martin said. “Yes, that’s happened a little bit, but not to the rate that it’s really going to solve rural and urban access problems.” A demonstrated benefit of such initiatives was seen in Arizona, which, five years after the adoption of

full-practice authority, saw a 50 percent increase in nurse practitioners as more moved to the state and were licensed, Cooke noted. The volume of nurse practitioners increased in more than 70 percent of rural counties in the state. Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

LEADERSHIP  July 2017

2017 NURSE PRACTITIONER STATE PRACTICE ENVIRONMENT

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M&A

LEADERSHIP  HFMA.ORG/LEADERSHIP

HOW CONSOLIDATION IS RESHAPING HEALTH CARE Ongoing trends have challenged healthcare stakeholders to improve care delivery by reducing clinical variation, while also increasing their access to capital. As a result, consolidation has become a defining factor in business models. By Elizabeth Barker With national healthcare expenditures increasing from 12.5 percent of GDP in 1990 to nearly 18 percent today, healthcare organizations are aiming to bend the cost curve. “If you’re going to figure out a way to slow down the increase of healthcare cost, you’ve got to figure out a way to get certain efficiencies and economies of scale,” notes Harry Kraemer, executive partner with Madison Dearborn Partners and clinical professor of strategy at Northwestern University’s Kellogg School of Management. Consolidation activity has increased steadily since 2009 and even doubled between 2011 and 2015.1 While change-of-control integration decreased last year, combination continues and increasingly is taking on a variety of forms other than mergers and acquisitions, such as joint ventures and affiliations. “We’re seeing a more organized way to deliver care and greater coordination among participants in what were once distinct verticals to provide that care,” says Anu Singh, managing director, Mergers, Acquisitions and Partnerships, Kaufman, Hall & Associates, LLC. A major question surrounding consolidation is whether this activity will lead to better care delivery and reduced costs. Mergers and acquisitions could decrease competition, while looser affiliations are not guaranteed to achieve aligned incentives. INDUSTRY TRENDS GUIDING CONSOLIDATION The shift from volume- to value-based payment and care delivery is driving healthcare providers to reshape their approach to care operations, such as by investing in technology to improve patient care and eliminate waste. “If reimbursement is now tied to population health measures along with the ability to use and make available electronic health records and to measure quality, you now need a new fixed infrastructure and group that you have to put in place just to be able to measure those things and keep them on the right side of the ledger,” says Howard Forman, MD, professor of Radiology, Economics, Public Health, and Management at Yale. Access to patient populations and management of patient health across the care continuum are central to population health management, challenging health systems to examine their resources and enhance their capabilities.

For instance, to strengthen care delivery through a population health management focus, Denver-based kidney care provider, medical group, and management company DaVita HealthCare Partners acquired Everett, Wash.- based physician group The Everett Clinic last year. Drawing from a robust physician network and broadening DaVita’s Howard Forman, MD, operations, the partnerprofessor, Yale University ship aims to facilitate integrated care delivery in northwestern Washington. “This partnership exemplifies the renewed collaboration between once-distinct verticals within the healthcare services space,” Singh says. Consumerism is requiring organizations to exhibit the value of their services and provide care in a more user-friendly fashion. For Danville, Pa.-based Geisinger Health System, which acquired Atlantic City, N.J.-based AtlantiCare in 2015, patient feedback has informed efforts to improve the patient experience across the care continuum. Both organizations have brought internal best practices to the partnership, implementing the C-I-CARE communication process to inform how clinicians and other staff interact with patients and each other, as well as sharing patient experience stories to identify opportunities for improvement. “Ultimately, healthcare consolidation will be judged by listening to our patients and learning how best to care for their needs,” Dominic Moffa, executive vice president and chief strategy officer with Geisinger, states in an email. THE CONSOLIDATION SPECTRUM Achieving financial strength, reducing clinical variation, increasing scale, and forming clinically integrated networks for improved care delivery are major considerations in various forms of consolidation, which encompasses activity ranging from mergers and acquisitions to affiliations and joint-operating agreements.2

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Mergers and acquisitions. Vertical and horizontal integration allows health systems to tighten operations, streamline services, and increase access to capital. Kraemer notes that assorted factors can influence the decision to merge. “Possibilities include but are not limited to increasing market share, improving cost position for efficiency and economy of scale, achieving aligned extension by moving into another product category, acquiring talent, and global expansion,” he says. Moffa states that elements of the Triple Aim— decreased costs, improved patient experience of care, and better management of population health—should guide any consolidation, citing a firm grasp of the population health model as the basis of integration between AtlantiCare and Geisinger. “We were health systems with common points of view and complementary goals,” he says. In this effort to more quickly achieve population health management goals to better serve the southern New Jersey community, AtlantiCare has extended its capabilities by utilizing Geisinger’s technology and care redesign model. The health system has implemented an integration plan involving shared goal setting and joint

planning along with transformation metrics related to Triple Aim goals—metrics include overall patient satisfaction, readmission rates, and cost per member—to determine the acquisition’s success. Affiliations and joint-operating agreements. Seeking to enhance the value of care while retaining their independence, some organizations are forging partnerships without a change of control. These combinations range from looser affiliations such as contractual relationships to more extensive financial alignments such as jointoperating agreements. In 2011, Rochester, Minn.-based Mayo Clinic launched Mayo Clinic Care Network, partnering with member organizations following a thorough evaluation process to lend its brand and expertise through telehealth.3 This contractual relationship provides members with access to clinically based services, including telehealth consultations with Mayo Clinic specialists for patient care; care tools; and, for member staff, consultations with Mayo Clinic experts in areas such as patient care, finance, and human resources. In an instance of increased financial alignment, Denver-based academic medical center University of Colorado and Fort Collins, Colo.-based community health system Poudre Valley formed University of Colorado Health through a joint-operating agreement in 2012. University of Colorado Health aims to improve the quality of care for an expanded patient population while the two consolidating entities retain control of their assets.

THE CONTINUUM OF STRATEGIC PARTNERSHIP STRUCTURES The structures of strategic partnerships range from loosely integrated contractual arrangements to fully integrated arrangements, with varying levels of commitment and financial alignment possible in many structures.

Increasing Level of Commitment

Increasing Financial Alignment

Contractual Relationship Affiliations

Joint Venture/ Operations

Full Integration

• Corporate Services Support

• Sale of Minority Interest

• Whole-Institution Lease

• Shared Clinical/ Ancillary Services

• Joint-Operating Agreement

• Change of Corporate Member

• Management Services Agreement

• Sale of Majority Interest

• Asset Sale/Acquisition

• ACO/CIN Development

Source: Allen, P.M., Finnerty, M.J., Gish, R.S., et al., “Guide to Health Care Partnerships for Population Health Management and Value-based Care,” Health Research & Educational Trust and Kaufman, Hall & Associates, LLC, June 2016. Accessed at www.hpoe.org.

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Regardless of the type of consolidation taking place, “The motivations remain around how to transition care from being volume-based to being more value-based and driving increased efficiency and efficacy of care delivery, which can result in geographic growth, deeper capabilities, or stronger infrastructure in supporting that care,” Singh says.

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“You have some flexibility in terms of how you capitalize and finance organizations, but you’re contributing the operations of the business to a new entity,” Singh says regarding joint-operating agreements. “We’ve seen joint-operating agreements pick up in pace, number, and size in terms of the revenue bases of the partnering organizations.”

Noting that the possibility of higher costs for patients in a less competitive marketplace is cause for concern, Moffa agrees that the potential value of each consolidation should be evaluated on a case-by-case basis, as recommended by America’s Health Insurance Plans (AHIP). “I share AHIP’s view that consolidation may help advance the goals that the health system is demanding—specifically, coordinated, high-quality care. We believe that’s been the case here at Geisinger.” With AtlantiCare’s diverse patient population in mind, Geisinger secured $5.5 million from the National Institutes of Health in 2016 to administer the Precision Medicine Initiative Cohort Program, a research initiative exploring ways to improve disease prevention and treatment.

EFFECT ON HEALTHCARE CONSUMERS Whether and to what extent consolidations will benefit consumers remains central to the conversation. In the past, for instance, health plan and provider consolidations have not necessarily resulted in lower prices for consumers. 2 Patient experience and changes in cost will help determine the impact of partnerships and integrations. In a joint venture with Procure Proton Therapy Center, Oklahoma City-based INTEGRIS secured access to proton treatment equipment in its market. Instead of having to finance equipment or refer patients out of area, the organizations can combine their strengths to facilitate management of patient health in the community. The consolidation has ensured increased access to care for patients in the Oklahoma City area. “You’re blending technology and financial and capital strategies to bring greater capabilities to health systems to offer patients new services locally,” Singh says. Recent proposals for combinations among national health plans have produced concern over decreased competition, which in the past has resulted in higher premiums for consumers and lower payments to providers.2 Such fears have influenced recent decisions to block Aetna’s acquisition of Humana and Anthem’s purchase of Cigna. With change-of-control transactions, the outcome may depend on the competitive environment, Kraemer says. “A merger or acquisition will benefit the consumer if two things happen: The companies’ coming together gets the benefit of efficiency and economy of scale, and at the same time it doesn’t reduce competition to the point where the combined company denies the cusAnu Singh, managing tomer at least as good of director, Kaufman, Hall & a price.” Associates, LLC

THE OUTLOOK FOR CONSOLIDATION Regarding the volume of consolidations and partnerships taking place, Singh states, “It’s not a positive or negative outcome; it’s simply a reality that all organizations in the industry will have to undergo some level of collaboration.” The success of consolidations may depend on different standards than before, considering industry changes that demand increased cost transparency, attention to patient feedback, and the ability to manage patient populations.2 Research reveals that partnerships founded on achieving value-based care have generated morepositive feedback in the industry than those focused on market power.4 As Geisinger’s Moffa notes, “Healthcare organizations will need to prove that these changes have created an environment in which consolidation does in fact improve value to the healthcare consumer.”

Dominic Moffa, executive vice president, Geisinger Health System

Elizabeth Barker is a digital communications professional and freelance writer in Chicago (elizabeth. hbbarker.gmail.com). Interviewed for this article: Howard Forman, MD, professor of Radiology, Economics, Public Health, and Management; director of the MD/MBA program; director of healthcare curriculum, MBA for Executives Program; and lecturer in Ethics, Politics, and Economics, Yale University, New Haven, Conn. (howard.forman@yale. edu); Harry Kraemer, executive partner, Madison Dearborn Partners, and clinical professor of strategy, Kellogg School of Management, Northwestern University; Dominic Moffa, executive vice president and chief strategy officer, Geisinger Health System ([email protected]); Anu Singh, managing director, Mergers, Acquisitions and Partnerships, Kaufman, Hall & Associates, LLC ([email protected]). FOOTNOTES: 1. “Mergers and Acquisitions: Strategy Takes Precedence Over Scale,” HFMA Buyer’s Resource Guide, 2017. 2. “Health Care 2020: Consolidation,” HFMA, November 2016. 3. “Guide to Health Care Partnerships for Population Health Management and Value-based Care,” American Hospital Association and Kaufman Hall, July 2016. 4. “Acquisition and Affiliation Strategies,” an HFMA Value Project Report, June 2014.

LEADERSHIP PERSPECTIVES

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Joseph J. Fifer, FHFMA, CPA, is president and CEO, HFMA (jfifer@ hfma.org). Follow Joe Fifer on Twitter @HFMAfifer. The opioid epidemic is garnering many headlines these days. But amid all the attention to the many negative impacts of addiction on people’s lives, one aspect is often overlooked. Having a substance use disorder— whether it involves prescription opioids, heroin, alcohol, or another drug—often doubles the odds that a person will develop another chronic and costly medical illness, such as arthritis, chronic pain, heart disease, stroke, hypertension, diabetes, or asthma, according to the Surgeon General’s comprehensive 2016 report, Facing Addiction in America.1 Yet the link between addiction and chronic conditions seemingly flies under the radar. MISSING OPPORTUNITIES FOR EARLY INTERVENTION The Surgeon General’s report states that providing services to people with mild and moderate substance use disorders in general healthcare settings is likely to reduce the need for intensive and costly treatment services later. This is not a radical idea. Early intervention is the

principle that underlies contemporary approaches to managing a wide range of chronic health conditions. So why have we missed the boat when it comes to addiction treatment? In part, it’s because addiction treatment has been separated from general health care. It’s compartmentalized. While there are valid reasons for this separation, it “has also created unintended and enduring impediments” to care, according to the Surgeon General. For example, separation reinforces the idea that substance use disorders are different from other medical conditions. Although many patients in emergency departments, hospitals, and general medical settings have substance use disorders, mainstream health care generally has failed to recognize or address them. Medical education in this area is inadequate, which perpetuates the problem. Training in substance use disorders at medical schools is focused on transmitting scientific facts rather than developing the attitudes and skills that would help physicians have difficult but crucial conversations with their patients. 2 TRACING THE TRAJECTORY According to the not-for-profit Facing Addiction organization (for which I am a board member), 20.8 million people suffer from a substance use disorder today, with another 23 million in recovery. That is similar to the number of people who live with diabetes and more than 1.5 times the number who have cancer. The number of people living with—and dying from—addiction is growing rapidly. Fatal heroin overdoses were more than five times higher in 2014 than in 2004. The admission rate for substance use disorder treatment in 2009 was six times the 1999 rate. In certain segments of the U.S. population, there has been a dramatic increase in

mortality from chronic liver disease and cirrhosis—both conditions that are linked to alcohol abuse—since the year 2000, reversing decades of progress.3 Alcoholism is currently overshadowed by the opioid epidemic, but it has most definitely not gone away. The downstream effects of these trends on healthcare utilization by addiction survivors will be significant. CONNECTING THE DOTS As I wrote about previously in this space, 93 percent of Medicare feefor-service spending is for patients who have multiple chronic conditions. We must improve management of these patients to curtail the growth of healthcare spending, which is projected to reach 20 percent of GDP by 2025. Managing chronic conditions is generally not a priority for those who work in hospital and health system settings. Chronic conditions are managed primarily in physicians’ offices and patients’ homes, whereas hospitals typically treat the complications of chronic conditions—complications that could be prevented if the conditions were better managed early on. As an industry, we need to do a better job of coordinating care so that people with chronic conditions—including addiction—receive the care they need in the appropriate setting. As the Surgeon General put it, it’s time to face addiction in America. FOOTNOTES: 1. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, D.C.: HHS, November 2016. 2. Ram, A., and Chisolm, M.S., “The Time Is Now: Improving Substance Abuse Training in Medical Schools,” Academic Psychiatry, June 2016. 3. Case, A., and Deaton, A., “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century,” Proceedings of the National Academy of the United States of America, Dec. 8, 2015.

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