Download Slide 1

Integrated Care
The Inseparability of the Mental and the Medical
CFHA Summit
San Diego, California
Frank deGruy
October 22, 2009
A Medical Home is:
“…responsible for providing for all
the patient’s health care needs…”
“Care is coordinated and/or
integrated across all elements…”
Joint Principles of the Patient Centered Medical Home
American Academy of Family Physicians (AAFP)
American Academy of Pediatrics (AAP)
American College of Physicians (ACP)
American Osteopathic Association (AOA)
February 2007
2
Without mental and behavioral healthcare,
the PCMH fails.
Fails!
3
Mental Disorders
Symptoms, Stress, Concerns
Substance Abuse
Health Behavior Change
4
Mental Disorders
5
Number of physical symptoms
6
The Full Cost of Poor Health to Employers
30%
Iceberg
of Full Costs to
Employers from Poor
Health
Medical Care
Pharmaceutical costs
Workers’ Compensation Costs
70%
Personal Health Costs
Productivity Costs
Absenteeism
Short-term Disability
Long-term Disability
Presenteeism
Overtime
Turnover
Temporary Staffing
Administrative Costs
Replacement Training
Off-Site Travel for Care
Customer Dissatisfaction
Variable Product Quality
Sources: Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study", JOEM.2009; 51(4):411-428. and Edington DW, Burton WN. Health
7
and Productivity. In McCunney RJ, Editor. A Practical Approach to Occupational and Environmental Medicine. 3rd edition. Philadelphia, PA. Lippincott, Williams
and Wilkens; 2003: 40-152
Top 10 Health Conditions Driving
Med + Rx Costs per 1000 FTEs
$200,000
$180,000
$160,000
$140,000
$120,000
$100,000
$80,000
$60,000
$40,000
$20,000
$0
Drug
Medical
Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study“. JOEM.
2009;51(4):411-428.
8
Top 10 Health Conditions Driving Full Costs for Employers
(Med + RX + Absenteeism + Presenteeism) Costs/1000 FTEs
$400,000
$350,000
$300,000
Presenteeism
Absenteeism
Drug
Medical
$250,000
$200,000
$150,000
$100,000
$50,000
$0
Loeppke, R., et al., "Health and Productivity as a Business Strategy: A Multi-Employer Study“. JOEM.
2009;51(4):411-428.
9
The Comorbidity Story
Robert Graham Center, “Why there must be room for mental health in the medical home;
NBGH: An Employers’ Guide to Behavioral Health Services
10
Health Behavior Change
11
McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270:2207-12.
Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004;291:1230-1245.
12
Myopia
Psoriasis
Hypothyroidism
Chronic Back Pain
Infertility
Crohn’s Disease
GERD
Allergies
Ulcerative Colitis
Motivation to change
Depression
Multiple Sclerosis
Sickle Cell Disease
Epilepsy
Type I Diabetes
Parkinson’s
Asthma
Cystic Fibrosis
CAD
Chronic Hep B
Schizophrenia
CHF
Type II DM
Alzheimer’s
Obesity
Osteoporosis
Cerebrovascular Dz
Hypertension
Hyperlipidemia
Bipolar Disorder
Requirement for behavior change
Addictions
So What Does A Comprehensive
Medical Home Look Like?
And where do we get the behavioral
horsepower we need for it?
14
The Shape Of Practices Today:
A solo doc in a micropractice
A doc and a nurse
Three partners, four staff
…joined by a care coordinator
…joined by a psychologist
Eight partners, three care coordinators, a clinical pharmacist, two
psychologists, and a partridge in a pear tree
Staff HMO office with a full complement of resources
FQHC with a different full complement of resources
15
Possible Structures
for Integrated, Comprehensive Care
A psychologist who does CBT both in her office and in the PCMH
A psychiatrist who is in the medical home one afternoon a week
A CMHC staff who are available any time by phone
An MFT who works part time in the practice
A Depression Center that consults by teleconferencing hookup
A psychiatrist who spends one long breakfast a week with the PCPs
and the Care manager reviewing charts
A psychologist who works with the care coordinator .25 FTE on
motivational interviewing and other health behavior change
modalities
16
Principles
Specify the job to be done
Pay for outcomes
Offer ideas and options about means
Encourage local solutions
Support the cost of change
Closely evaluated case studies and demos
17