ValueOptions Integrated Care Initiatives

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NASHO 4th Annual Leadership SummitAugust 1 2,
2006 Value and Profitability in Specialty
Partnerships
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Creating Better Outcomes Through Specialty
Partnerships NASHO Leadership SummitAugust 2,
2006
Kristina L. Greenwood, Ph.D. Vice President,
Outcomes Research
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Setting the Stage for Partnerships

• Although considered a specialty vendor,
  ValueOptions has re-defined our services to
  overcome the artificial silos between medical
  behavioral health.
• Re-definition was prompted by the facts that
  mental health and substance abuse problems are
  significantly under-diagnosed and under-treated.
• Results from the National Co-morbidity Survey
  Replication Study
• Nearly half of all Americans will meet criteria
  for a DSM-IV disorder sometime during their
  life1, with approximately 26 meeting criteria
  during a one-year period.2
• Most people with mental disorders are either
  untreated or poorly treated.3 Although the
  majority of people eventually access services,
  the median delay is approximately 10 years4 and
  ranges from 6 to 23 years, depending on the type
  of disorder.
• Traditional model Wait for members to
  eventually seek services
• New model Proactive identification outreach,
  plus innovative interventions
• Laying the foundation to support this new
  perspective
• Conducted extensive literature reviews and our
  own independent research to demonstrate the
  potential for improved outcomes and cost savings.
• Developed a wellness-disease model to guide the
  development of comprehensive population health
  strategies.
• Designed the essential features of the program,
  and collaborated extensively with key early
  adopter clients.

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Behavioral Health Co-Morbidity Study Methodology

• ValueOptions conducted a co-morbidity study, in
  collaboration with Integrated Healthcare
  Information Services (IHCIS), using a national
  commercial claims database of 3.8 million
  members.
• Our goal was to understand the impact of
  behavioral health co-morbidity on a broader scale
  and across multiple diseases.
• Sample included members who were eligible for
  behavioral health benefits, with analyses of
  medical, pharmaceutical, and behavioral claims.
• Research focused on the following
• Prevalence of co-morbid behavioral health
  conditions for various physical health diseases.
• Impact of behavioral health conditions on the
  utilization and costs of physical health care,
  after excluding the services related to mental
  health treatment.

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Prevalence of Behavioral Health
Co-Morbidity Across All Risk Groups
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Co-Morbidity Impact on Physical Health Care
Costs Across All Risk Groups
Note Reflects PMPM costs for all physical
health care services, after excluding the PMPM
costs for behavioral health services.
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Co-Morbidity Prevalence and Cost
Impact Stratified by Risk Group
Cost Increase Associated with Co-Morbidity For
1,000 Patients
Prevalence of Co-Morbidity by Risk Group
Note Reflects increased costs for all physical
health care services, after excluding the costs
for behavioral health services, for members with
co-morbid depression and/or anxiety. The member
population was stratified into High Risk (top
10th percentile), Moderate Risk (11th to 50th
percentile), and Low Risk (bottom 50th
percentile) categories using IHCIS Episode Risk
Group (ERG) model.
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Co-Morbidity Prevalence and Cost
Impact Stratified by Risk Group
Cost Increase Associated with Co-Morbidity For
1,000 Patients
Prevalence of Co-Morbidity by Risk Group
Note Reflects increased costs for all physical
health care services, after excluding the costs
for behavioral health services, for members with
co-morbid depression and/or anxiety. The member
population was stratified into High Risk (top
10th percentile), Moderate Risk (11th to 50th
percentile), and Low Risk (bottom 50th
percentile) categories using IHCIS Episode Risk
Group (ERG) model.
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Co-Morbidity Study Conclusions

• This study demonstrates the significant
  prevalence of co-morbid behavioral health
  conditions among multiple chronic diseases.
• However, these results are likely an
  under-representation of the true prevalence, due
  to the use of claims data to determine the
  incidence of a behavioral disorder.
• True prevalence rates are also likely to be
  higher since members are not typically screened
  for behavioral health symptoms by their
  physicians, and often do not access mental health
  services on their own.
• The diagnosis of substance use disorders was
  especially low, reflecting less than 1 of the
  sample, so cost impact analyses were not
  possible.
• Across all risk categories, the impact of
  co-morbid depression/ anxiety on physical health
  costs (excluding mental health treatment) ranges
  from nearly a 50 increase to 135 (mean 81
  standard deviation 25.5).
• This pattern of results was consistent across
  various chronic physical health diseases, even
  after adjusting for the severity of the disease.

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Definition of Integrated Care

• Based on this study and past research, we
  formulated a new conceptual model of wellness and
  disease management to support integrated care
  programs.
• ValueOptions Integrated Care definition
• The use of behavioral health disease management
  and/or lifestyle modification strategies to
  improve co-morbid physical health outcomes.

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Wellness and Disease Management Model
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Wellness and Disease Management Model

• The impact of lifestyle behaviors on the
  development, course, and treatment outcomes of
  many chronic physical health diseases is well
  established.
• As a result, intervention programs generally
  focus on disease management and/or incentives to
  promote and maintain healthy lifestyles.

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Wellness and Disease Management Model

• The impact of Behavioral Health has not been
  adequately addressed in many intervention
  programs. Such disorders may significantly limit
  individuals willingness and capacity to
  participate in self-care activities, due to
• Lack of energy, motivation feelings of
  hopelessness
• Functional impairment
• Cognitive impairment
• Therefore, behavioral disorders may contribute to
  members refusal to participate in intervention
  programs at all, as well as high attrition rates.

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Considerations for Designing Integrated Care
Programs

• The significant impact of behavioral health
  co-morbidity warrants consideration in the
  development of disease management and integrated
  care programs.
• Research evidence demonstrates that early
  identification and treatment of behavioral
  disorders can result in improved adherence,
  positive health outcomes, and cost-effectiveness.
• A meta-analysis of 58 controlled studies of brief
  psychotherapy found decreases of 10 - 33 in
  health care utilization in 85 of the studies.5
• A comprehensive meta-analysis of 91 studies in
  medical populations concluded that 90 of the
  studies reported some degree of decreased medical
  utilization following psychological
  intervention.6

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Elements of Integrated Care Programs

• Identification of members across systems based
  on specific diagnoses, sentinel events, and/or
  use of predictive modeling tools
• Outreach including education and support tools
• Assessment of needs, establishing baseline status
• Interventions that focus on coordination to
  maximize improvement and prevention, including
• Coordination of treatment among PCPs, medical
  specialists, behavioral health providers, disease
  management vendors, and community resources
• Member participation in intensive care/ disease
  management protocols
• Promotion of self-help and preventive care
  resources
• Health coaching programs to improve treatment
  adherence and facilitate healthier lifestyles,
  even for members without a formal behavioral
  health diagnosis
• Monitoring of compliance, improvement and
  outcomes
• Evaluation of program success

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Considerations for Creating Partnerships

• Partnership guidelines for optimal collaboration
• Emphasize a truly integrated care approach,
  rather than a sole focus on physical or
  behavioral disease management.
• Develop specific workflows across multiple
  vendors (determine touch points, referral
  triggers, and opportunities for consultation).
• Look for and eliminate redundancies, to improve
  member ease of use and reduce administrative
  costs.
• Define specific parameters for pilot projects
  based on available resources, including scope,
  key milestones, and time period.
• Establish how outcomes will be tracked and
  evaluated prior to implementation.

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Expected Results from Integrated Care Projects

• ValueOptions has several ongoing integrated care
  projects with health plan and employer clients
• Expected results include
• Increase in physical and mental health status, as
  measured by the SF-12 Health Survey
• Decrease in depressive symptoms, as measured by
  the Patient Health Questionnaire (PHQ-9)
• Decrease in substance abuse problems, as measured
  by the Alcohol Use Diagnosis and Identification
  Test (AUDIT)
• Decrease in healthcare utilization and costs,
  based on analyses of claims data
• Decrease in prospective risk scores, as measured
  by predictive modeling tools
• Increase in compliance with evidence-based
  treatment guidelines
• Change in specific indicators, depending on
  program focus, such as decreased BMI for Weight
  Management program

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References

• Kessler R.C., Berglund, P., Demler, O., Jin, R.,
  Merikangas, K.R., Walters. E.E. (2005).
  Lifetime prevalence and age-of-onset
  distributions of DSM-IV disorders in the National
  Comorbidity Survey Replication. Arch Gen
  Psychiatry 62(6) 593-602.
• Kessler, R.C., Chiu, W.T., Demler, O.,
  Merikangas, K.R., Walters, E.E. (2005).
  Prevalence, severity, and comorbidity of 12-month
  DSM-IV disorders in the National Comorbidity
  Survey Replication. Arch Gen Psychiatry 62(6)
  617-627.
• Wang, P.S., Lane, M., Olfson, M., Pincus, H.A.,
  Wells, K.B., Kessler, R.C. (2005). Twelve-month
  use of mental health services in the United
  States results from the National Comorbidity
  Survey Replication. Arch Gen Psychiatry 62(6)
  629-40.
• Wang, P.S., Berglund, P., Olfson, M., Pincus,
  H.A., Wells, K.B., Kessler, R.C. (2005).
  Failure and delay in initial treatment contact
  after first onset of mental disorders in the
  National Comorbidity Survey Replication. Arch Gen
  Psychiatry 62(6) 603-613.
• Mumford, E., Schlesinger, H.J., Glass, G.V., et
  al. (1984). A new look at evidence about reduced
  cost of medical utilization following mental
  health treatment. Am J Psychiatry, 1411145-1158.
  
• Chiles, J.A., Lambert, M.J., Hatch, A.L.
  (1999) The impact of psychological interventions
  on medical cost offset A meta-analytic review.
  Clinical Psychology Science and Practice 6
  204-220.

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VSPs Eye Health ManagementSM
ProgramPresented bySusan Egbert, MBADirector
of Utilization and Quality Management
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Agenda

• Trends in Healthcare
• The Eyecare Connection
• VSPs Eye Health ManagementSM Program

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Trends in Healthcare

• Healthcare costs are rising
• Nearly 25 increase in two years
• Cost of Chronic Illness
• 44 of Americans with chronic disease account for
  78 of total costs

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Trends in Healthcare

• Employers Response

Source Mercer's 2005 National Survey of
Employer Sponsored Health Plans
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The Eyecare Connection

• In 2004, 61 of Americans reported wearing some
  form of vision correction
• 95.2 million (43.2) of US adults received eye
  exams LTM
• 35.64 million (16.2) of US adults saw a
  physician for a preventative exam LTM

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The Eyecare Connection
The eyes are the only place on the body where the
blood vessels can be evaluated non-invasively.
In addition to eye health conditions, following
are examples of systemic conditions that can be
detected.
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Eye Health ManagementSM Program

• Assist in improving patient outcomes and managing
  healthcare costs
• Identifying and treating conditions at the
  earliest stages
• Raising awareness of the importance of regular
  eye exams
• Providing tools for eye doctors to facilitate
  coordination of care
• Sharing data with third parties (health plans, DM
  companies) to assist with disease management and
  wellness strategies

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EHM Program Components

• Doctor Tools
• PCP Form Patient Eyecare Report
• Client Tools
• Presentations Literature Value Calculator
• Member/Public Awareness
• W2W Campaign Trade Shows Articles

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EHM Doctor Tools
Eye care for the patient with diabetes requires
a partnership between the primary physician,
the eye-care specialist, and the patient. --
Centers for Disease Control
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Member/Public Awareness
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Eye Health ManagementSM Program
DM Program
Lab Data
Healthplan Data
Pharmacy Data
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Eye Health ManagementSM Program
Medical Data Collection Tool
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Eye Health ManagementSM Program

• Initial Results
• Tens of thousands of patients identified
• Shared live diabetic patient data with large
  healthplan
• Eight percent of the diabetic patients VSP
  identified were previously unknown to the
  healthplan
• An additional 12 are potential diabetics

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Eye Health ManagementSM Program

• Cost Implications
• Managing diabetes 1,200 to 4,000 per patient
  per year in cost avoidance
• Managing hypertension 1,900 cost avoidance per
  patient per year
• Managing heart disease 3,000 to 6,000 cost
  avoidance per patient per year

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Eye Health Management

• Its who we are, what we believe
• and what weve been doing for over half a
  century

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Creating Better Outcomes Through Specialty
PartnershipsImproving Outcomes Through the
Addition of a Chiropractic Benefit
Presented by R. Douglas Metz, DC Chief Health
Services Officer
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Relevant Outcomes

• Benefits of evidencebased complementary health
  care
• Managed Chiropractic Care.

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Relevant Outcomes

• Clinical Effectiveness
• Safety
• Patient Satisfaction
• Appropriateness of Care
• Cost

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I. Clinical Effectiveness

• Low Back Pain
• Headache
• Neck Pain

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I. Clinical Effectiveness (Low Back Pain)

• Most improvement with Spinal Manipulative
  Treatment (SMT) is seen very early in the course
  of treatment.
• Back pain patients who self-select to MDs and DCs
  appear to have a similar severity profile.
• Effectiveness SMT for LBP demonstrated in
  controlled trials.

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I. Clinical Effectiveness (Low Back Pain)

• SMT has been shown to be equal or superior to
  other conservative therapies (PT, exercise) in
  most studies, but...
• It has proven very difficult to demonstrate
  clinically or statistically significant
  differences among various conservative therapies.

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I. Clinical Effectiveness (Headache)

• Tension and Migraine headaches respond equally
  well to SMT.
• Migraine with and without aura respond equally
  well to SMT.
• Side effects profile for SMT is much more benign
  than for amitriptyline.
• SMT more effective than soft tissue treatment for
  cervicogenic headache.

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I. Clinical Effectiveness (Neck Pain)

• SMT and strengthening exercise appear equally
  effective for the treatment of cervical spine
  pain.
• Purely passive care is less effective.
• PT modalities add no benefits.
• There is higher patient satisfaction with
  chiropractic care.

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II. Safety (Severe Adverse Events)

• Cauda equina syndrome
• CVA following cervical manipulation

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Nearly all members agree that the provider and
staff are concerned about their personal health
and well-being.
q1. The provider and staff are concerned about my
personal health and well-being.
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Nearly all members agree that the provider and
staff ensured their safety during their visits.
q2. I feel the provider and staff ensured my
safety during my visit.
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II. Safety (Severe Adverse Events)

• Cauda equina syndrome Estimates of frequency
  range from 1 episode/1 million manipulations to 1
  episode/100 million manipulations.
• CVAs following cervical manipulation
• Any CVA 5-10/10 million manipulations
• CVA with permanent neurological deficit 3-6/10
  million manipulations
• CVA resulting in death lt3/10 million
  manipulations
• Recent studies have failed to identify any
  abnormal forces on vertebral arteries from SMT

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II. Safety (Severe Adverse Events)

• In 76 RCTs (over 25,000 treatments), there have
  been no reports of severe adverse events.

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II. Safety (Severe Adverse Events)

• Cerebrovascular accidents after manipulation
  appear to be unpredictable and should be
  considered an inherent, idiosyncratic, and rare
  complication of this treatment approach.

Haldeman S, Kohlbeck F, McGregor M.
Unpredictability of Cerebrovascular Ischemia
Associated With Cervical Spine Manipulation
Therapy. Spine. 20022749-55.
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II. Safety What We Know

• The overall safety record of SMT is excellent.
• The safety/side effects record is particularly
  impressive when compared to other commonly used
  treatment options (NSAIDS, tricyclic
  anti-depressants, surgery) that have similar
  effectiveness results.

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III. Patient Satisfaction Carey TS, etal.. N
Engl J Med. 1995 Oct 5333(14)913-7.
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ACCESS to CARE The majority agree they are able
to get an appointment at convenient time and
location. (lt 6v)
q3. I was able to get an appointment at a
convenient time and location.
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OUTCOMES of CARE Most members agree that their
provider is successful in treating their
condition. (lt6v)
q5. The provider was successful in treating my
primary condition.
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PROVIDER RECOMMENDATION Most members would
recommend their provider to their family and
friends. (lt6v)
q4. I would recommend this provider to my family
and friends.
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Key satisfaction measures
Most agree they would recommend their provider.
(gt6v)
Provider recommendation
Top 2 box (strongly or somewhat agree) Bottom
2 box (somewhat or strongly disagree)
You would recommend this provider to your family
and friends
GH
(n533)
(n495)
Q19. The following items focus on the experiences
you had with the ltspecialistgt. Please indicate
the extent to which you agree or disagree with
each of them.
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Key satisfaction measures
Most believe they receive high quality treatment
from their provider. (gt6v)
Overall provider rating
Top 3 box (excellent, very good or
good) Bottom 2 box (fair or poor)
Overall, how would you rate the quality of the
care and services you received
(n531)
(n503)
Q25. Still thinking about the most recent care
you received from the ltspecialistgt, for which
part or all of the care was paid for by your
insurance benefits, please rate each of the
following.
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Key satisfaction measures
The high quality of treatment received and the
perceived competence of the provider translate
into a high level of satisfaction. (gt6)
Overall provider satisfaction with recent visit
Top 3 box (completely, very or somewhat
satisfied) Bottom 3 box (somewhat, very or
completely dissatisfied)
(n505)
(n539)
Q26. All things considered, how satisfied or
dissatisfied were you with your most recent visit
to the ltspecialistsgt office?
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IV. Appropriateness of Care Legorreta Metz,
etal Archives Internal Medicine, Oct 2004.

• Rates of specific diagnostic and therapeutic
  procedures
• Analysis Period 1997-2001
• Rate Per 1000 low back pain episodes

p value lt0.001
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IV. Appropriateness of Care

• Rates of specific diagnostic and therapeutic
  procedures
• Analysis Period 1997-2001
• Rate Per 1000 neck pain episodes

p value lt0.001
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IV. Appropriateness of Care

• Rates of specific diagnostic and therapeutic
  procedures
• Use of plain film radiographs for Low Back Pain
  
• Analysis Period 1997-2001
• Rate Per 1000 Low Back Pain episodes

p value lt0.001
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IV. Appropriateness of Care

• Rates of specific diagnostic and therapeutic
  procedures
• Use of plain film radiographs for Neck Pain
• Analysis Period 1997-2001
• Rate Per 1000 neck pain episodes

p value lt0.001
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V. Cost (Low Back Pain)

• Average Cost Per Episode and Per Patient
• Includes Combined Episodes
• 1997-2001

p value lt0.001
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V. Cost (Neck Pain)

• Average Cost Per Episode and Per Patient
• Includes Combined Episodes
• 1997-2001

p value lt0.001
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Benefits of a Managed Specialty Health Program

• Clinical Effectiveness
• Evidence Supported Tx Protocols
• Safety
• Favorable Safety Profile
• Patient Satisfaction
• High Member Satisfaction
• Appropriateness of Care
• Excellent Outcomes Profile
• Cost
• Contributes to Lower Costs

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ASH Companies
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NASHO 4th Annual Leadership SummitAugust 1 2,
2006 Value and Profitability in Specialty
Partnerships