QUIZ 2: UTILIZATION MANAGEMENT: AN EVOLVING APPROACH TO MANAGING CARE

UTILIZATION MANAGEMENT – A FOCUS ON THE COORDINATION OF HEALTH CARE SERVICES FOR PLAN ENROLLEES WITH MULTIPLE CHRONIC CONDITIONS

People with chronic health conditions often have co-occurring mental health disorders, and several provisions in the Affordable Care Act address the need for comprehensive treatment of physical and mental health conditions.

In addition, people with severe and persistent mental illnesses (such as schizophrenia, bipolar disorder or major depression) also need a range of services and supports that are parallel to those needed by people with chronic physical health conditions.

The Need for Chronic Care:

Chronic diseases are prolonged conditions or illnesses that require ongoing treatment and are generally treatable but not curable. Diabetes, cancer, and heart disease are common examples.

Chronic health conditions affect almost half of all Americans1and each year seven of every ten deaths result from chronic conditions, making them the leading cause of death and disability in the United States.2Chronic health conditions also account for three quarters of health care spending.3

People with serious mental illnesses experience especially high rates of chronic health conditions. Extensive data conclusively demonstrate the association between mental illness and other chronic disorders such as cardiovascular disease, diabetes, cancer, asthma and obesity.

According to the Centers for Disease Control and Prevention, the occurrence, course and outcomes of chronic disease are affected by a co-occurring mental illness.4Those who have a co-occurring mental illness tend to experience worse outcomes than others and their poorer health status correlates with higher healthcare costs.

For a person with a serious mental illness, having a co-occurring chronic health condition also affects the efficacy of treatment for the mental illness. People with serious mental illnesses generally have trouble obtaining primary care and often encounter long delays before they receive a diagnosis and effective treatment for a chronic health condition. This is evidenced by the high rate of untreated or poorly treated physical disorders in this population (especially diabetes and cardiovascular, pulmonary and infectious diseases). The result is that individuals with serious mental illnesses served by the public mental health system die, on average, 25 years earlier than people in the general population.

To achieve better health outcomes for all individuals with chronic conditions and to stem the rate of health spending on chronic care, the Affordable Care Act encourages the development of a variety of chronic care strategies. These include:

· Collaborative care models, including medical or health homes, co-location of primary care and mental health services, accountable care organizations, community health teams and Medicare special needs plans;

· Specialized services, including home-based services, medication management;

· Preventive services;

· Research, outcomes and quality of care measurement, testing of new innovations and expansion of the workforce.

Collaborative Care Models

Health care delivery models that entrust one entity with the comprehensive management and coordination of an individual’s care have been found very effective in treating chronic disorders.

Such systems offer an opportunity for prevention and early intervention and can form a basis for improving quality and making care more affordable.

These strategies have been developed because the standard, fragmented, acute care that is typical in the American health care system is not effective in treating the complex needs of individuals with chronic illnesses, especially those who have more than one chronic condition. The ACA encourages coordinated and collaborative care through various options for states, providers and communities.

In a collaborative care model, primary care and behavioral health professionals can be co-located in order to offer easy access to mental health treatment for people with chronic health conditions whose recovery is impaired by a co-occurring mental health disorder. For more complex cases, health homes can provide improved referral and linkage with community mental health specialty care.

Medical/Health Homes :

Several provisions of the ACA encourage the creation of more organized care for people with chronic health conditions through

Medicare and Medicaid medical/health care homes, accountable care organizations or specialized health care plans, termed Special Needs Plans, in Medicare.

Medicaid Health Homes:

The law includes several provisions to encourage the establishment of medical or health care homes that assume the responsibility of overseeing the whole health of the individual.

For those on Medicaid, the ACA promotes collaborative care by creating a new state plan option to establish “health homes. “These health homes will serve individuals who have at least two chronic conditions, one chronic condition and a risk of developing another, or a serious and persistent mental health condition. In states that take this option, individuals will then have the choice of participating by designating a qualified provider as their “health home.” States are encouraged to take up this option through an increase in the federal Medicaid rate to 90% for the first two years the state option is in place.

A health home may be a single provider, a coordinated team of providers or a community mental health provider agency. Health homes will be required to meet certain federal standards and provide specific services, including comprehensive care management and coordination, health promotion, transition services from inpatient to other settings, patient and family support, and referrals to appropriate community services.

Community mental health centers are specifically listed in the law as being eligible for designation as a health home. Community mental health centers, which often serve as the only source of care for individuals with severe mental illnesses, can provide coordinated primary care services in familiar, comfortable locations. Mental health professionals may also participate as part of any health home clinical team. States are required to consult and coordinate with the federal Substance Abuse and Mental Health Services Administration (SAMHSA) when a health home will address the prevention and treatment of mental health and substance abuse issues for enrollees with chronic conditions.

ACA authorizes $25 million for planning grants to states interested in developing Medicaid health homes. States receiving a planning grant must contribute a state match (equal to their Medicaid match rate). States must also include both a system for tracking avoidable hospital readmissions and calculating savings that result from improved chronic care coordination and management, and a plan for incorporating the use of health information technology to improve service delivery and coordination across the continuum of care.

Co-location of Mental Health and Primary Care Services:

The ACA authorizes specific grants to community mental health agencies to co-locate primary care services in the mental health agency, essentially creating a specialized health home for adults with serious mental illnesses who have co-occurring chronic conditions or who need primary care services. $50 million is available to eligible qualified community mental health programs.

The co-location of primary care and mental health services offers many advantages and potential benefits for people with serious mental illnesses.

Consultation between mental health and primary care providers becomes routine, and quality of care and outcomes improve. Additionally, too often the only routine health care received by people with serious mental illnesses is from their mental health providers in

community mental health settings. Providing primary care services in a setting that is already familiar and accessible may make it easier for consumers to keep appointments and to follow through with their providers and course of treatment. This provision goes into effect immediately, and funds are made available until 2014.

The Medicaid health home state-plan option similarly would permit community mental health agencies to co-locate primary care services in order to offer holistic care to individuals with serious mental illnesses (see above).

Community Health Teams:

Under the ACA, grants are authorized for the development of Community Health Teams by states and other entities to support the patient-centered medical home concept.

This program will establish community-based interdisciplinary, inter-professional teams of health providers to support and work with local primary care providers so as to provide comprehensive management and coordination of an individual’s care and ensure collaborative services.

Teams may include primary care providers, specialists, including mental health providers, other clinicians and licensed integrative health professionals.

Teams will work together to coordinate disease prevention, chronic disease management and case management, with specific attention paid to individuals with chronic conditions.

They must agree to provide services to individuals who are eligible for the Medicaid Health Care Homes option described above. The program will be effective when funding is made available through appropriations.