Behavioral and Physical Health Integration: The Need for Delivery System and Payment Reform KENNETH E. THORPE, PH.D. EMORY UNIVERSITY KTHORPE@EMORY.EDU
Issues Forcing Payment and Delivery System Reforms • Chronic disease accounts for rising share of healthcare spending. Accounts for 86% today compared to 67% in 1987. About 90% of the growth in Medicare spending since 1990 due to rising chronic disease prevalence • Largest increase is among patients with multiple chronic conditions • Total health care spending among patients with a mental disorder account for 44% of Medicaid and 31% of Medicare spending
Approximately 16Percent of Adults have a Diagnosed Mental Disorder – Most with a Comorbidity 60 56.8% 50 40 30 20 12.7% 11.4% 11.8% 10 7.2% 0 0 Mental Disorder 1 Comorbidity 2 Comorbidity 3 Comorbidity 4+ Comorbidity
Most Common Comorbid Conditions Among Those with a Medical Disorder 45 40% 40 35 33% 32% 30 24% 25 23% 20 15 10 5 0 Hypertension Hyperlipidemia Arthritis Endocrine Pulmonary Disease
Needed Reforms • The growth, diversity and complexity of patients with multiple chronic conditions requires interdisciplinary care teams for coordinating care. These teams need to be developed (though the personnel exists). Medicare can help accelerate the development of these teams. • Need for collaborate care and community health teams • Silo based fee for service payments continue to focus on single patient conditions rather than the whole person. Alternative payment models can promote care across treatment silos and integrate team based care coordination into the care process
The Connector — Interdisciplinary Community Health Teams • The Connector teams would provide the links between Visiting population and community Nurse/Home Hospitals Health Agency health interventions and more Primary Specialty Care & traditional medical care Care Disease Management Practice treatment. Any provider or health Programs Connector Health Team plan could use the teams to Patient and family Primary Psychologists/psychiatrists serve this connector function. Care Social, Economic, & Nurse Coordinators Practice Community Services Social Workers • An RTI evaluation found that the Nutrition Specialists Primary Community Health Workers community health teams Mental Health & Care Public Health Specialists Substance Abuse generated approximately a 4:1 Practice Pharmacists Programs ROI for Medicare Primary Care Self Management Practice Workshops Public Health Programs & Services Multi-Insurer Payment Reform Framework Health IT Framework • Evaluation Framework Based on Vermont Blueprint for October 21, 2103 6 Health
How Do We Get There? • Need both payment returns and organization of the multi- specialty teams. • Move away from silo- based payments into “aggregated” and population – based payment • CMS can build team based care coordination into traditional Medicare by redirecting existing CPT coordination codes and contract directly (through competitive bidding) with salaried care teams
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