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This Web site is a component of the SAMHSA Health Information Network. |
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Organization & FinancingSAMHSA Managed Care Initiative Training SessionsDecember 1997
Dates: December 11, 1997-Parklawn Conference Center, Rockville, Maryland
Title: Integration of Behavioral Health Care and Traditional Medical Care
As representatives of the Southern California Permanente Medical Group, Drs. Radcliffe and Cook, and Pamela Morales, R.N. presented the Kaiser-Permanente model of the integration of behavioral health care and traditional medical care. Pamela Morales, R.N., M.H.A. Redesign Overview Ms. Morales began her segment of the presentation with a brief overview of the Southern California Region of Kaiser-Permanente and provided a historical perspective on behavioral health care services prior to the organizational redesign in 1995. The Southern California Region extends from San Diego to Bakersfield and services 2.5 million members. Within the Region there are 23 locations for Psychiatry and 10 locations for Addiction Medicine. Before the redesign, psychiatric services consisted of inpatient admissions, one-on-one counseling, and limited group therapy. Outpatient services were available only on weekdays during the hours of nine to five. Addiction Medicine had two subregional centers that were open 24 hours/day, seven days/week, offering inpatient detoxification and outpatient services. Other Addiction Medicine facilities were generally limited to "business hours" (nine to five) during the week, with few evening hours, and all were closed on weekends. By 1995, Kaiser-Permanente purchasers (employer groups and labor trust funds) determined that the current status of behavioral health care was not meeting the needs of their representative groups, and began to demand that some changes be made. (Kaiser Permanente defines "behavioral health care" as the services offered by both Psychiatry and Addiction Medicine. Ms. Morales explained, however, that Addiction Medicine is part of the basic medical plan, with equal parity with all other medical services. Psychiatry, however, is purchased as a "supplement" to the basic benefits, with different levels of service and charges, depending on the purchasers' decision.) In addition, the purchasers wanted some data that substantiated the value of the integrated approach to behavioral health care, as opposed to opting for a "carve-out" program through a managed behavioral health care service. Southern California Kaiser Permanente responded in several ways. They (1) employed the consultants that had been used to evaluate the behavioral health care services of the Kaiser Permanente Northern California Region to perform the same services for their region; (2) established a Purchaser Focus Group, comprising the ten major purchasers in the state, to obtain opinions and insights into behavioral health care service needs; and (3) benchmarked the Region's services internally, against other Kaiser regions, and externally, with other Health Maintenance Organizations (HMOs) and other managed behavioral health care companies. This input was analyzed and evaluated. The report that was issued recommended specific changes which were determined to be necessary in order to remain competitive in area of behavioral health care. In January and February 1996, all Chiefs of Service of Addiction Medicine and Psychiatry and Department Managers met to begin to implement the recommendations of the report. They began with the establishment of performance standards and goals, which served as the cornerstone for the organizational redesign and provided for consistency of services across the Region. The overall theme was one of following basic performance standards, tailored to meet the needs of each specific area's service population. The performance standards concentrated on five key areas:
As a final piece, a Purchasers' Council was established. The Council's purpose is to provide a forum where the Purchasers can provide their "advice and consent" regarding the plans and programs of the regional behavioral health care services. It has proven quite successful and also has served as a barometer for Kaiser to measure customer satisfaction. Dennis Cook, M.D. and Anthony Racliffe, M.D.-Performance Standards Dr. Cook described how Psychiatry reorganized to meet the performance standards developed in the behavioral health care services redesign. Specifically, over the last several years, psychiatry has:
In addition, because the Southern California Region has a strategic advantage of a large member population, Kaiser has the ability to offer those patients best treated in a group setting access to group therapy in areas such as depression, anxiety disorders, relational problems, and child and adolescent problems. The performance standard goal to conduct 20 percent of psychiatric services in a group setting has been met across the region. Dr Cook described an innovation that has helped Kaiser behavioral health care services better meet the needs of its members. Because inpatient psychiatric services do not have parity with medical services, there are various limitations on patient benefits. Through the California Department of Corporations, which oversees such programs, Kaiser established an "exchange" program. For example, one psychiatric inpatient hospital day may be exchanged for two days of day treatment or three days of intensive outpatient treatment. This is particularly helpful for the severely mentally ill, who may not need 24-hour hospitalization, but are in need of more intensive treatment than a typical outpatient setting. This has enhanced Kaiser's ability to treat, and has resulted in expanded coverage for the patients by matching them to the modality that will most effectively meet their needs. Also, the continuum of care was expanded to complement treatment, and now includes intensive outpatient appointments, 23-hour beds, (23-hour beds refers to voluntary patient care for up to 23 hours, without "commitment") and 24-hour beds This has been helpful in providing the infrastructure that is necessary to treat chronically mentally ill patients successfully. The intensive case management component also gives Kaiser the ability to follow these patients very carefully and all service areas in behavioral health now use this tool. Another innovation is the presence of EAP liaisons in all the service areas. These people interface with Kaiser employee groups and appropriate human resource personnel. Data collection has improved. More than 90 percent of the cases seen in Psychiatry and Addiction Medicine now have diagnostic codes, which allows Kaiser to utilize the data more efficiently and effectively. For example, the data are now organized around diagnoses, and analyses of the programs can now be done in terms of who is being treated, the best ways of treating patients, and treatment success. This information can be shared internally within Kaiser and externally to Kaiser purchasers. Additionally, the behavioral health program is in the process of establishing an Outcomes Management System, which will provide "on-line" or "real time" feedback on various parameters of patient improvement. With this information, appropriate adjustments-both clinically and programmatically-can be made along the treatment path. Until this process is complete, Global Assessment of Function (GAF) scores currently are used with each patient encounter to evaluate quality issues. Dr. Radcliffe stated that, because Addiction Medicine is considered a basic medical benefit, coverage is similar to any other health condition, such as cancer or diabetes. The only exclusion in coverage in Addiction Medicine is methadone use, although the physicians are currently working to obtain approval for its use. He then described how Addiction Medicine reorganized to meet the performance standards developed in the behavioral health care services redesign. Specifically, over the last several years, Addiction Medicine:
Because Addiction Medicine at Kaiser is part of the basic healthcare benefit package, there is no option of refusing services or concern for exhaustion of benefits. Dr. Racliffe emphasized how this approach is supported by articles in the recent literature that suggest limiting these benefits simply pushes patients to providers who are not properly trained to provide the treatment necessary-which, in the long run, is more expensive for a health plan. Currently, both Addiction Medicine and Psychiatry are working as equal partners with consultants in an effort to develop a strategic plan in the area of outcomes management. This will include mental health inpatient/outpatient tools and a measurement tool that is effective in Addiction Medicine. The result will be a strategic plan that allows providers to look at a complete outcomes management process that can be used when the clinician is seeing the patient. Conceptually, it will be similar to a lab test or a computer printout that will assess the patient in terms of their functioning; their socialization; and their symptomatolgy. Dennis Cook, M.D. and Anthony Racliffe, M.D.-Integrated Delivery System Dr. Cook suggested that Kaiser Permanente, as a "closed system," does have some distinct advantages in the integration of behavioral health care and traditional medical care. He first, however, pointed out a few "realities" of a closed system that must be acknowledged. Although behavioral health care has been part of Kaiser's integrated system for the last 30 of Kaiser's 50 years, it is one of 26 departments that competes for budgeted health care dollars. Each department, therefore, has to effectively demonstrate their value to remain competitive. At the same time, in such a closed system, if something is ignored in one department, it will "bulge" out in another. In behavioral care terms, this particularly applies to the chronically mentally ill who, if not treated in behavioral care, will not "drop" out of the system, but "bulge" out to primary care. The result is treatment in less cost effective conditions and with poorer quality-of- care methods. Given such dynamics, the closed system's specific advantages in the area of collaboration with primary care include the following, for example:
Collaboration also is enhanced by the fact that in adult primary care, 25 to 50 percent of the visits either are primarily for a behavioral health care problem or co-morbid with a behavioral health care problem and a medical problem. This provides a strong rationale for effective collaboration. The challenge of such collaboration is that this is a "work-in-progress." There is no "right way," but it is a matter of looking at available resources and who you are collaborating with. In terms of professional collaboration, it is essential to keep in mind there is no such thing as "the" primary care physician. Primary care physicians vary enormously in their background, interest, and training in behavioral health care; also in age, and self-selection processes. The collaboration is with each individual provider and his/her patients, not with departments or modules. Variations in patient population, such as age, cultural, and ethnic differences are additional factors to consider in terms of the kind of collaboration and types of programs to offer. In addition, successful collaboration will require choices that have cost implications. The choice must be weighed against both the cost and the overall impact it will have. For example:
Successful and effective collaboration is a matter of looking at where and how to match patients, providers, and resources, trying a variety of options, and making adjustments along the way. Dr. Racliffe then emphasized several components that are essential for successful collaboration and provided several examples. One is ongoing dialogue. For example, in initial discussions with primary care physicians, they likened mental health and chemical dependency to a "black hole," where patients disappear into and no results are ever forthcoming. This was exacerbated by confidentiality issues, which often prohibited the sharing of information that was a normal process with other specialities. They explained to their behavioral health colleagues that their collaborative needs included information on (1) diagnosis; (2) laboratory test results; (3) changes in medication; and (4) treatment plans. Another essential component is the education of primary care physicians regarding situations when behavioral health care collaboration can be applied to a primary care diagnosis. Dr. Racliffe cited chronic, nonmalignant pain, a common primary care complaint, as an example. He explained that behavioral care providers can help to determine if prescription drugs are being abused or misused or if there is there a danger in their use. They then can share this information with the primary care physician, and co-counsel the patient and their family members to help them to understand some of the potential or very real dangers. An emerging trend is the use of behavioral health care services by the families of drug-addicted patients and nicotine addicted patients, as well as chronic pain patients. In summary, he emphasized that a true integrated healthcare system is generally a slow and steady, ongoing process, requiring many different approaches that continually add another perspective to whomever is the patient's "doctor," while maintaining the special bond between physician and patient. Ultimately, integration in health care systems must be anchored in two thoughts: (1) a patient-focused approach, and (2) what is best-which, in itself, must be a collaborative process involving both physician and patient.
Question and Answer Session
17: What percentage of mental health cases are treated in primary care? Also, what is the process of referral to mental health? 1: First, let me state that our system does not have gatekeepers-approximately 70 percent of those treated in psychiatry are self-referred. About 90 percent of those in Addiction Medicine are self-referred, perhaps with a little arm twisting from a primary care provider or Employee Assistance Personnel. The bulk of Psychiatric and Addiction Medicine care that is not performed in the specialty departments is performed in adult primary care. The best data that we have is that the primary psychotrophic medications that are prescribed are antidepressants and probably in the range of 50 percent of antidepressants are prescribed by primary care physicians. 17: What is the number of self-referrals versus primary care referrals and is any routine mental health screening done in primary care? 1: In our system, because it is a basic benefit, we have a primary screening for both addiction and psychiatry when the member comes into the health plan system. There is a secondary screening at the primary care level appointment. For Addiction Medicine, that has picked up approximately 15 to 25 percent of the patients that come to us; the vast majority are self-referred. 17: What percent of the population that you treat would be categorized as severely mentally ill? 1: I don't have crisp data on that, because it is an evolving population. I can tell you that the largest impact in this regard comes from our commercial population (as opposed to MediCAL population) as they may be spouses of members who are covered through their employment. This is the group that is evolving as we had not been treating this population previously and now they are moving into the health plan. It is not a large group, but an expensive one. 17: Another population is the heroin addicted. What does Kaiser offer this population in terms of scientifically-based clinical treatments? 1: The heroin addiction treatment is just like for any other drug treatment problem, with the exclusion of methadone. That is something we are now trying to overturn because the Purchaser Groups have told us that they want methadone treatment covered as a basic benefit. All the providers want methadone covered, as we feel it is a useful adjunct treatment. We also make use of Employee Assistance Program personnel who are advocates at the workplace for employees and have great influence over the types of services that employers demand. We have Employee Assistance Liaisons at all our facilities throughout the service area. 17: In the competitive California market do you find that the establishment of particular mental health benefit and/or addiction benefit provides a certain competitive advantage when you approach purchasers? 1: We have certain strategic advantages because of the integration of Psychiatry and Addiction Medicine, as well as that of behavioral health care services with traditional medical care. As far as the specific benefits, although there are some similar benefits offered by our competitors, we are the integrated model and moving even more in that direction has provided the edge. 17: Is that at a higher cost of premiums? 1: We are actually at a lower cost than our competitors, however, our scope of services is broader. Although many of our purchasers have told us that they would be willing to pay more, if the services are provided and are effective. 17: Do you have any evidence in competition for contracts in either the public or commercial sector that the quality of the programs you are providing have actually won contracts rather than cost? 1: That is a key question. One of the things we are involved in trying to add to our behavioral health care program is outcome systems-not just outcome measures. That is a critical piece because up to now the dialogue has been around cost, amount of services, and patient satisfaction-which is not a very good outcomes measure. Beyond that, we have not found any very good outcomes systems in behavioral healthcare to determine if people really do get better. 17: You're dealing with an aspect of quality and an amount of service and managed care, as an institution, has often dealt with the issue of cost. The link question has become: are people willing to pay more for additional or better service? What about prevention, early identification, and intervention? What are the commercial purchasers willing to pay in this regard? 1: One of the pieces of the redesign, the Purchasers' Council, is talking to us about wellness programs. They also would like information, such as how many of their people were seen for certain diagnoses, what are the age groups, and what kind of services? Such information can help to influence their worksite wellness programs. They are also looking to partner with us in those programs. Preventive Medicine is a part of the basic health plan benefits at Kaiser, so members have access to those services. 17: Do you have any data at all on the marketing value of preventive services such as primary screening, health education, neonatal screening, pregnancy and substance abuse screening? 1: It depends on the organization. Some progressive organizations would see some value in that and would be willing to invest some money in those services; others, who are more economically embattled, would not. 17: Because of the competition in the California market, do you find your staff model approach under any pressure to disassemble? 1: People now are offering many fragmented services. Our system works and has the advantage of being a totally integrated system. We will remain the same because we feel it is the right way. We can work together, as a system, to treat the whole patient. Purchasers also are seeing that, in the long run, a system without integration will not treat patients effectively and cost more. 17: Can you give me an update on the Kaiser hospitals and the status of the Northern and Southern California Health Plans-are they still separate? 1: The Kaiser Permanente Medical Groups (Northern and Southern California) are separate entities, although we are moving toward better collaboration with each other in terms of common practice guidelines and similar issues. The Medical Groups are now under a California Division, which means that the Health Plan and Kaiser hospitals are one division across the state. There is currently some attempt to look at both the number of Kaiser hospitals and what we are doing with the hospitals. 17: Your set your performance standard for first encounter access as within five days. The NCQA (National Council for Quality Assurance) stated that, for the Health Plan Employers Data and Information Set (HEDIS 3.0), the HMO will be rated on how it meets its own internal benchmarks. This gives you the leeway to set your own standards. What was the rationale for the five-day standard? Is there any citation for that standard? 1: Kaiser did not set these performance standards internally. We relied on the information and analyses of consultants, based on information from purchasers, members, and competitors. They told us that this was an appropriate performance standard that would be satisfying to members and be competitive. These performance standards are an evolving process. We will be responsive to member demands and to the competition. In terms of a citation, we don't have one, but can ask the consultants and follow up with you. 17: Does this five-day standard in mental health coincide with other areas of medicine? 1: The standards for each department are based on market pressures and that is what will drive the response time. 17: Is there any truth to the analysis that market share will shape the response to market pressure? 1: Yes. A market share of 29 to 30 percent penetration rate will dictate a different response than a 10 to 15 percent. For example, we will respond to a Point of Service (to use non-Permanente physicians) request with a lot more flexibility if our penetration rate can be significantly improved. 17: Do you survey people who drop out? Do people have the option to drop-out annually or quarterly? 18: Members do have the option to drop-out annually, at the end of their contract year and we do survey members who leave Kaiser. The turnover rate has been consistently decreasing from the late 80s. 17: You mentioned more family involvement in addiction medicine, and mentioned more family usage. Are your Purchasers aware of this involvement? 1: The Purchasers are aware of it. One of the things we did in the early 80s was to look at the utilization of other health services by both the addicted person, as well as the family members and found that the family used more medical services than the actual patient. We want to show that if we help these people they will not overuse or inappropriately use the other services. This is one purpose of outcome studies-to have that kind of data. Family members are tremendously affected by any chronic disease, and to act as if they don't have any need for help is ridiculous. 17: Do you do any community outreach? 1: Yes. For example, we are involved in health fairs on a regular basis and the Los Angeles school district suicide prevention team. We have an extensive community services program and youth services in all of our service areas. We also realize that it offers a strategic advantage. 17: Are you planning on looking at the extent to which community service outreach coordination improves treatment outcomes? 1: Part of the redesign effort is to include treatment outcomes. We had made plans to work with a company, but they declared bankruptcy a week before the pilot program was to go into effect. Many of their tools were propriety, so we couldn't use them. As discussed in our presentation, we are working on a clinical instrument that will be useful to providers and will evaluate and measure outcomes on a real-time basis. We didn't think much about a community service piece; although it is an interesting concept. 17: Do you tend to see most of the patients in your offices or do you go out to the community? 1: We see them in our offices. 17: Have you considered the use of interactive technologies? What about telemedicine? 1: An interactive technologies pilot was conducted in our Northern California Region. In our region, patient education is available through interactive computers. Another technologies piece is with special interest groups, for example patients who are HIV positive, who communicate via computer. In addition, there has been some very limited use of telemedicine. 17: Although I have heard some discussion, why hasn't the model of the placement of appropriately trained mental health providers in non-specialty facilities been implemented more universally? 1: Ideally, in a health model your not interested in waiting until someone gets to metastatic cancer before you diagnose the disease. You're not particularly interested in the disease model. You'd like to deal with prevention as a basis. What is needed here is education in behavioral health care services-education of the patient-and the intervention by the physician, and we haven't done that very well. The inclusion of mental health professionals in the primary care setting, however, is a very expensive model. It raises the question of where is Psychiatry and Addiction Medicine in the medical food chain? To move to that kind of model in a closed system-with the recognition that there is a very real value in that and the allocation of appropriate resources-the resources must come at the expense of some other area. There also is the issue of fitting into the scheduling of primary care; how to impact people that are seen in primary care within the time frame that the patients are coming in the door. In other words we have to work to be acceptable to or collaborate with an existing model that we have very little influence over.
Question and Answer Session
17: Kaiser Permanente always has offered integrated services. Could this reorganization be classified as an "upgrade?" 1: Yes. Our services always were integrated. But, although our Addiction Medicine services were very well thought of competitively, Psychiatry had lost some of its competitive edge over time. 17: Did your redesign involve changes in the formal benefits? 1: It did not result in changes in the written benefits. All Kaiser Permanente health care contracts contain a statement allowing "alternative programs," and partial hospitalization always was written into the contracts-so we had the ability to initiate these changes. In addition, the contacts are written in very "general" language, so there was no need to rewrite the contracts. The "exchange system"program and any expansion of services, however, did require State approval before we could offer it to the purchasers. 17: Why did the State have to approve expanded services? 1: Because the state of California requires Department of Corporation approval before health maintenance organizations remove services or add inpatient-services. 17: Based on the array of services available, how do members know their specific benefits? 1: As we have meetings with Purchasers during their contract reviews, benefits/services that are available to their members are explained and written information is sent to the groups to inform them of additional/expanded services. Also, specific benefits are explained to the patient on a case-by-case basis. 17: How does it become cost effective if you are offering significantly enhanced benefits? 1: Actually it's a "win-win" situation. Kaiser can provide more services in a more cost effective manner. Through "tailoring" benefits to patient needs we can provide the appropriate level of care and not use unnecessary services. 17: Where do you draw the line between what Kaiser Permanente should offer and what you expect members to receive through publically funded programs? 1: At this point we have a very small MediCAL (California Medicaid) population- approximately 50,000 out of 2.5 million. The subpopulation of that group that would affect us is the persistently mentally ill. Those of our commercial members who are persistently mentally ill have a family member that is employed and, therefore, have coverage. So there has been very little impact and, thus far, we have not had to deal with that issue-although over time this may change. 17: You mentioned that, because of resource limits, it is difficult to fully serve high utilizers. If I understand the continuum of care tradeoffs, you still do some sort of per person budget calculation so that you can say the patient received the equivalent of the yearly benefits that are covered under your contract and eventually end treatment. 1: Conceivably that could happen. Remember that psychiatry doesn't have full parity with other medical services. What we are hoping is that with this expansion of services, by January 1998, we can target those patients who are in need of stabilization and be able to expand their outpatient group benefits without cost to them. Another thing we are adding is those visits for medication checks would not be charged as an outpatient psychiatric or psychotherapy visit, but simply at the same rate as a routine internist physician visit. We also have established dual-diagnosis programs in all our service areas to enhance the collaboration and to use services more efficiently. However, ultimately, some may have to go to the public sector. 17: How was it decided to include substance abuse as a fully covered benefit and have psychiatry a discretionary benefit? 1: That was determined by California State legislation when they created managed care. As a point of clarification, psychiatry is covered as a basic benefit-at a certain minimum- and may be purchased at certain levels. Addiction Medicine was moved to the medical side because of the issues of detoxification and need for physical assessment. 17: You mentioned that Purchasers want information from you about behavioral health programs. What do they do with this information? 1: They use it to determine what areas they should concentrate on in their health fairs and Employee Assistance Programs. 17: Do you think this is true only for your section of the country? There is a slight disconnect between what you are saying the surveys that I have read indicating that the general trend in mental health and substance abuse continues to be increasing limitations on these benefits. 1: Unlike most states, California is a heavily managed care state. Our major purchasers are now beginning to realize that the cost of disabilities associated with behavioral care is more than the cost of treatment. New surveys that are about to be published will substantiate that limitation of behavioral health care services is simply a method of cost shifting, and that, in fact, this is not limiting care, but "pushing" it off to people who may be ill equipped to deal with these types of problems. This is part of a trend. At first it was "cost control," now we're seeing "quality intensity" which may (hopefully) spread across the country. 17: Given the fact there is no "best" model of integration, are there any "bad" models? Anything intrinsically "bad" about carve-out programs? 1: "Bad" would probably be characterized as trying to fit a square peg in a round hole-in other words-any "cookie cutter" or "one size fits all" approach. It is essential to assess the interests, attitudes, and needs of the primary care physician regarding behavioral health care and go from there. An add-on to that is the patient. You cannot put models on patients that they do not want, nor can you ignore their relationship with the primary care provider or the psychiatrist. In terms of carve-outs there are intrinsically difficult parts and an intrinsically bad part. The difficult part is the issues of trust and collegiality which is just not there naturally when you are not part of the culture. That is not to say it cannot be established, but it is more difficult. The other is that there is a pervasive sense of cost shifting when there is capitation. If there is capitation, it is to each provider's benefit (primary care and mental health) to shift the costs to the other component. 17: Are there cases where patients do not want their primary care physicians to be informed about their behavioral health care services? 1: It does happen. It was a concern, if for no other reason than it may be detrimental to patient health, not to mention integration. We were advised by our legal department that information sharing between medical colleagues/medical partners treating the same patient is permissible, if lack of sharing can cause harm/danger. That is the premise we work under with such cases, even though the patient may be irritated and we realize there is the possibility of court action. NOTE: Too few evaluation forms were returned to perform a reasonable analysis. |
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