Policy Considerations for Integrated Care
Chuck Ingoglia, Senior Vice President, Public Policy and Practice Improvement
This presentation at a glance
- Post-election: Affordable Care Act moves forward
- Many battles shift from federal to state level
- Issues in ACA implementation:
- Exchanges
- Insurance market regulation
- Medicaid expansion
- Federal level: fiscal cliff, deficit reduction, Medicare & Medicaid reform
- Delivery and payment innovation proceeds
- Issues to watch
The Affordable Care Act: Four Key Strategies
Healthcare Reform
- Insurance Reform
- Coverage Expansion
- Delivery System Redesign
- Payment Reform
Forces at Play
- Experimentation
- Liberation of information
- Demand for impact
- Monopoly economy
Health reform moves forward… but what are the implications for…
- Health insurance regulations?
- Exchanges? State, Federal or Partnership Fate of subsidies for buying coverage in exchanges?
- Medicaid expansion? Many states still opposed
- Medicare reform?
- Deals on budget, debt ceiling, tax reform, sequestration, tax cuts, deficit reduction?
Types of Plan |
Must offer MN/SUD? |
Parity spplies? |
Plans sold in Exchanges (Qualified Health Plans) |
X |
X |
Individual market (not sold in the Exchanges) |
X1 |
X |
Small group market (not sold in the Exchanges) |
X 1 |
0 2 |
Large group market (not sold in the Exchanges) |
0 |
X 3 |
Traditional Medicaid, fee-for-service |
0 |
0 |
Traditional Medicaid, managed care |
0 |
X3 |
Benchmark Medicaid for newly eligible, FFS |
X |
Partially 4 |
Benchmark Medicaid for newly eligible managed care |
X |
X |
Innovations under CMS,
Jonathan Blum, CMS
- Payment reform; fundamental shift away from fee-for-service
- Delivery system reform: encourage reorganization of system to take out waste and deliver high-value care
- Different opportunities for providers based on readiness
- Strategic partnerships with data
- Robust quality monitoring
- Emphasis on multi-payer strategies and approaches
States' plans for dually eligible individuals
|
Capitated managed care states are: |
Managed FFS states are:
|
States that are Both: |
States not pursing demo are: |
States |
Oregon, California, Idaho, Arizona, New Mexico, Texas, Minnesota, Wisconsin, Illinois, Michigan, Ohio, Tennessee, South Carolina, Virginia, New York, New Hampshire, Vermont, Massachusetts and Hawaii |
Colorado, Oklahoma, Iowa, Missouri, North Carolina, Connecticut |
New York and Washington |
Montanna, Wyoming, Nevada, Utah, North Dakota, South Dakota. Kansas, Indianna, Pennsylvania, Maine, Mississippi, Alabama, Louisiana Florida, Georgia, Arkansas, New Jersey, Delaware, Maryland, Washington D.C., and Kentucky |
…and from a business planning perspective
Shifts in revenue sources as more people become eligible and enroll in new insurance options
Increased competition as health providers meet new value-based purchasing standards built on health system partnerships and accountability for clinical outcomes
Connect with other providers
- Coverage expansions are ONLY sustainable with delivery system reform
- Collaborative Care
- Patient Centered Healthcare Homes
- Accountable Care Organizations
- Accountability and quality improvement are hallmarks of the new healthcare ecosystem
Core Components of Collaborative Care
|
Two New Team Members |
Two Processes |
Care Manager |
Consulting BH Expert |
Systematic diagnosis and outcomes tracking
(e.g. PHQ-9 to facilitate diagnosis and track depression outcomes)
|
- Patient education/self-management support
- Close follow-up to make sure pts don't fall through the cracks
|
- Caseload consultation for care manager and PCP (population-based)
- Diagnostic consultation on difficult cases
|
Stepped Care:
- Change treatment according to evidence-based algorithm if patient is not improving
- Relapse prevention once patient is improved
|
- Support medication Rx by PCP
- Brief counseling (behavioral activation, PST-PC, CBT, IPT)
- Facilitate treatment change/referral to BH
- Relapse prevention
|
- Consultation focused on patients not improving as expected
- Recommendations for additional treatment/referral according to evidence-based guidelines
|
Questions:
Is your clinical delivery process supportive of "stepped care"?
The ability to rapidly step care up to a greater level of intensity when needed? The ability to step care down so that a consumer's MH/SU care is provided in primary care with appropriate supports?
All offered from a client-centered, recovery-oriented perspective?
Upcoming CPT code changes
- Removal of evaluation and management (E&M) plus psychotherapy codes from the psychiatry section
- Deletion of pharmacologic management (providers to use appropriate E&M code)
- Inclusion of add-on codes for psychiatry (services performed in addition to a primary service/procedure)
- Addition of code 90785 for interactive complexity
- New code for psychotherapy for a patient in crisis
http://www.thenationalcouncil.org/galleries/policy-file/CPT%202013%20Changes%20Fact%20Sheet.pdf
Questions may be directed to: