Policy Consideration for Integrated Care

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



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


Questions may be directed to: