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What are Commercial Health Plans Doing To Improve Behavioral Health Care Quality? Doug Nemecek, MD, MBA Senior Medical Director September 28, 2010 Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 1 Best Practices in Health Plan Behavioral Health Programs Evidence-Based Approach Integrated Data - Medical, Pharmacy, Behavioral Open Access Education and Support for Patients and Families Collaborate with Health Care Professionals 24/7/365 Telephonic Support Improve Health Increase Productivity Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 2 Screening Depression Screening • Lifestyle Management programs, Health Coaching, Disease Management programs, Case Management • • • • • • • • • • Low Back Pain COPD Renal Disease Migraines Diabetes Fibromyalgia Pregnancy HIV Cancer And More Alcohol Screening • Lifestyle Management programs, Health Coaching, Disease Management programs, Case Management • • • • • • • • • • Low Back Pain COPD Pancreatitis Osteoarthritis Pregnancy Pneumonia Hepatitis C Heart Failure Cancer And More Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 3 Clinical Screening Toolkit Health Benefit carriers, employer groups, and epidemiologists increasingly recommend the use of validated screening instruments to identify individuals with undiagnosed disorders, to monitor ongoing symptom severity, and to assess outcomes in clinical practice. Where necessary, CIGNA Behavioral Health has obtained permission from copyright holders for use and distribution, and supports clinical excellence by making the following validated instruments available for these purposes: Instrument: Patient Health Questionnaire - 9 (PHQ-9) Patient Health Questionnaire - 15 (PHQ-15) Patient Health Questionnaire - Brief (PHQ-Brief) Alcohol Use Disorders Identification Test (AUDIT) Alcohol Use Disorders Identification Test - "C" (AUDIT-C) Description: Links: Self-report instrument: 9 depression symptoms scored on scale and one additional question on functional impairment to screen and monitor depression symptom severity. Tool Self-report instrument: 15 somatic symptoms scored on a scale to screen and monitor for somatic symptom severity. Derived from the PRIME-MD diagnostic instrument for common mental disorders. Tool Self-report instrument: 8 questions scored on scale and one additional question on functional impairment. Identifies depression and panic disorder while providing measurement of recent psycho-stress and functionality, including some gender-specific sources of stress. Tool Self-report instrument: 10-items identify and monitor adult alcohol consumption that is harmful or hazardous to their health. Tool Brief version of AUDIT is AUDIT-C, which uses the first three questions from the AUDIT. Tool Instructions For Use Instructions For Use Instructions For Use Instructions For Use Instructions For Use STABLE resource toolkit For the screening, assessment, monitoring, and education for persons with depression and bipolar disorder. Tools and Instructions for Use Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 4 Proactive Identification For individuals that take the Patient Health Assessment Self-Reported risks targeted for outreach: • • • • • • Stress Drug Use Alcohol Life Satisfaction Job Satisfaction Absence Telephonic outreach will also occur for Stress or Alcohol if individual is ranked ‘high’ in intervention Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 5 The Depression Program - Member Support Identification • Review of claims and referrals • Focus on those treated by PCP or OB/GYN Opt-out approach • Individual “in” unless opts out • Mail-only option – but can call coach at any time Member Stratification • Level 1: Low Risk • Letter with phone number for individual coaching • Level 2: High Risk • Call to introduce program and schedule first “coaching call” Standard assessments to create personalized plan • PHQ-9, PHQ-15, Alcohol screening and referrals Personal coach assigned, plan developed Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 6 Intensive Case Management Focus on patients with complex clinical conditions and at the highest risk for hospital admission and re-admission • readmission within 180 days • opiate use/abuse • chronic pain • psychotic disorder, first admission Dedicated care manager Assistance with appointment reminders Coordination with medical and behavioral providers Education and empowerment Identification of community and other resources Regular telephone contacts with patients, family members and treating providers Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 7 Health Plan Behavioral Health Website Employer-specific logon • Product customization, co-branding Provider directory and web referrals 20-question well-being evaluation Health management resources • Coaching, audio seminars, articles, self-assessments Healthy Rewards® discount program • Eye care, hearing care, online drugstores, fitness clubs My Reminders • online tool allows you to set up recurring reminders that will be e-mailed to you • Appointment reminder tool Depression Online Tool • Secure, convenient support at no cost • Information about depression and how to overcome it • Articles on topics like building your support team Self-Assessment • designed to help gauge the current state of your behavioral health, give a snapshot of your emotional, social outlook, your stress level and general well-being Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 8 Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 9 Online Provider Directory CIGNA privileges providers across 14 clinical specialties Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 10 Multicultural Network Improvements Opportunity 2007 Winner: NCQA Innovation in Multicultural Health Care Award Increase cultural and language support for diverse members Fewer than 1 in 11 Hispanic Americans with a mental disorder contact a mental health specialist Action Ethnic Health Providers Added to Behavioral Network Collected voluntary information from practitioners such as gender, 1,200 ethnicity and language spoken Result Almost 50% increase from those responding most favorably when asked how well their practitioner met their cultural, linguistic, or specialty needs 50% increase in behavioral network practitioners with diversity of race/ethnicity, languages spoken, religion and sexual orientation Number Practitioners 1,000 800 600 400 200 0 2001 2002 Hispanic Impact 2003 2004 2005 2006 Asian/Pac Isl African Amer Native Amer Other Achieved significant increases in satisfaction and access for minority patients Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 11 Treating Behavioral Conditions – Practitioner Support Behavioral conditions often present in Primary Care settings. The following links and resources are intended to support Primary Care Physicians in assessing, treating, and/or referring commonly seen behavioral problems. CIGNA encourages collaboration between behavioral and medical settings and the coordination of behavioral health and medical care. Depression: • • • Printable Depression Practice Guidelines Participant Tool Kit Practitioner Tool Kit Bipolar Disorder: • • • Printable Bipolar Disorder Practice Guidelines Participant Tool Kit Practitioner Tool Kit ADHD: • • • Printable ADHD Practice Guidelines Participant Tool Kit Practitioner Tool Kit Alcohol and Other Drug Abuse: • • • Guide to Helping People Who Drink Too Much Participant Tool Kit Practitioner Tool Kit Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 12 Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 13 Performance Results 6 Spotlight at CIGNA Behavioral Health Project Highlights: Reducing Readmissions • Those in Intensive Care Management have shown a significant reduction in readmissions, increase in medication adherence, and a healthcare cost reduction of $3,000 per member. Call Center Redesign • Decrease Customer Service and Personal Advocate call transfers 40% (from 4,0006,000/month to 3,000; $4/call) Improving Alcohol/Drug Treatment Engagement • Improve HEDIS Initiation and Engagement measures, adding to CIGNA value equation • Initial improvement in treatment initiation from 35.9% to 47.0%. Enhancing the Privacy Culture • Improve employee awareness and compliance as indicated by audit scores; posttraining audit is indicating a 25% improvement. Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 14 14 Intensive Case Management 6-Sigma Study Increase in medication compliance Reduction in inpatient admissions and readmissions Emergency room visits decreased Overall medical and behavioral health outpatient costs remained controlled Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 15 ICM - Improvement Overview Increased the inpatient referrals from 15% to 30% with a statistically significant improvement (P Value= 0.000) The reach rate in 2009 compared to 2008 did not achieve statistical significance, but the volume improved considerably- 1400 were reached in 2008, while 2393 individuals were reached in 2009. Completion of the Program improved from 17% to 25% (P Value= 0.000) Engagement Rate: In 2008, the results were 36% and after our interventions in 2009 the results were 54%, a statistically significant improvement (pvalue=0.000). The 30-day readmission rate for engaged individuals was 6.0%, as compared to the non-engaged population of 8.2 % (P-Value = 0.008). Costs savings, from 2008 to 2009 for the engagement readmission rate was estimated at $1,068,694. Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 16 Clinical Integration: Behavioral & Pharmacy Complex Psychiatric Case Management Clinical algorithms screen for prescriptions in multiple therapeutic classes of psychotropic medications & multiple medications in a class. A six-month study revealed: $0.15PMPM savings 18% reduction in medical and pharmacy costs OxyContin ® Management Program Pharmacy claims help identify patterns of drug use that are of concern. First year results: $2.5 million savings 3,900 members identified & outreached Year-over-year dosage reductions Antidepressant Improvement Outcome Program Helps providers identify members needing closer depression medication monitoring. 3 year improvements: One-time fill rate decrease from 16.10% to 15.3% Medication compliance improved from 48.22% to 54.3% Narcotics Therapy Management Provider-based initiative identifying members with six or more narcotic analgesics prescriptions. Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 17 Outcome Measures – Bipolar Disorder Improvements The annual outcome goal: • Medication Persistence Rate • 2007 Baseline:48%, • Current measure: 2009 58% Monthly goals: • Medication Adherence rate: 80% to 84% • Letters to Prescribers: 59.5% to 45% • Outreach to Individuals: 12% to 38% Admission Rates: • There is a 15.15 % drop in bipolar admissions between the baseline year of 2007 and the intervention year of 2009 Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 18 Improving Behavioral Health Care Quality Questions? Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2008 CIGNA. 19