GOOD MORNING. IT IS A
PLEASURE TO OPEN THIS VERY
INTERESTING PANEL. I WANT TO
THANK EVERYONE FOR THEIR
ATTENTION AND PARTICIPATING IN
IT IS.
THIS IS SOMETHING THAT IS
CRUCIAL IN MANY WAYS FOR SUCCESS
IN DELIVERING SCIENCE FOR
INTERVENTION AND TREATMENT AND
SUSTAINING THEM AND THAT IS THE
ECONOMICS BEHIND IT.
IN GENERAL, WE HAVE FOCUSED VERY
MUCH ON RESEARCH THAT TARGETS
THOSE THERAPEUTIC INTERVENTIONS
WITHOUT PAYING ATTENTION ON THE
PRACTICALITIES OF ENSURING THAT
THOSE INTERVENTIONS WILL BE
SUSTAINED OR MAINTAINED THROUGH
DIFFERENT ENVIRONMENTS AND WHERE
UPON HEALTH ECONOMICS BECOMES SO
VERY CRUCIAL. WE CAN DESIGN
THERAPEUTICS THAT ARE VERY, VERY
EFFECTIVE IN THE LABORATORY
SETTING.
AND THEN WE SEE THEM DIE WHEN
THEY ARE BROUGHT INTO THE
CLINIC. THEY NEVER MAKE IT
AVAILABLE FOR PEOPLE THAT NEED
THEM WHO DON'T TAKE BENEFIT FROM
THEM.
THIS IS WR UPON HEALTH ECONOMICS
AS I HAVE SEEN IT SHOULD BE AN
INTEGRATED PART OF THE RESEARCH
AS WE DESIGN IT AND DO IT AND
EVALUATE IT. IT IS NOT JUST
WILL IT BE -- WILL IT MAKE A
DIFFERENCE IN THE PROCESS THAT
WE ARE LOOKING AT BUT IS IT IN A
WAY THAT IT CAN BE SUSTAINED BY
THE SYSTEMS THAT WE HAVE BUILT
TO DO THAT TREATMENT AND
SERVICES THAT FOLLOW THEM.
HOWEVER, AS I LOOK ON, TODAY YOU
WILL HEAR SOME VERY INTERESTING
PERSPECTIVES ON HEALTH
ECONOMICS.
YOU WILL SEE THEM AND I'M
SUPPOSED TO SPEAK ABOUT
SUBSTANCE USE AND OVERDOSES AND
THEN WE HAVE MENTAL HEALTH.
I WANT TO START BY SAYING THAT
WE SHOULD BASICALLY RECOGNIZE AS
WE ARE SPEAKING ABOUT HEALTH
ECONOMICS THAT IT MAKES NO SENSE
OVERALL TO SEPARATE SUBSTANCE
USE FROM MENTAL HEALTH
CONDITIONS.
IF THERE IS GOING TO BE -- I
MEAN, A WAY THAT WE CAN BRING
THEM INTO THE CLINIC, WE HAVE TO
FIGURE OUT HOW TO INTEGRATE THEM
BETTER.
THE REALITY BEING IS THAT WE CAN
IMPLEMENT AN INTERVENTION FOR
SUBSTANCE USE DISORDER. IF WE
ARE NOT IMPLEMENTING IT
COMPLEMENTARY FOR MENTAL HEALTH
CONDITION THAT IS SO FREQUENTLY
MORBID, IT IS VERY LIKELY THAT
THE PERSON THAT IS RECEIVING THE
TREATMENT WILL NOT RESPOND
PROPERLY.
SIMILARLY, IF WE ARE NOT
SENSITIVE TO THE CRUCIALNESS OF
MONITORING SUBSTANCE USE IN
PEOPLE WITH MENTAL ILLNESS, WE
MAY BE MISSING AN OPPORTUNITY TO
ACTUALLY DO AN INTERVENTION THAT
WILL IMPROVE THEIR OUTCOMES OF
MENTAL DISORDER ITSELF.
SO I THINK THAT I WOULD LIKE TO
START BY SAYING THAT AS WE GO
THRU OUT THE DISCUSSION ALL DAY
LONG THAT WE NEED TO CONCEIVE OF
MODELS ABLE TO INTEGRATE THESE
TWO CONDITIONS THAT ARE PART OF
THE BRAIN DISORDERS AND FOR
WHICH BIOLOGY HAS TOLD US ALL
ALONG THAT ACTUALLY OUR COMMON
FACTORS THAT MAKE PEOPLE
VULNERABLE TO THEM AND VIA
GENETIC VULNERABILITIES OR
ENVIRONMENTAL AND DEVELOPMENTAL
PROCESSES THAT MAKE YOU
SENSITIVE TO ONE OR HIGHER RISK
FOR ONE OR THE OTHER. THERE IS
ENORMOUS OVERLAP AND LOOKING AT
STUDIES OF THE BRAIN, YOU WILL
FIND OUT THERE IS NOT A
PARTICULAR REGION OF THE BRAIN
BELONGING TO ADDICTION AND ONE
TO SERIOUS MENTAL ILLNESSES.
IN FACT, THE BRAIN WORKS THROUGH
PROCESSES AND EXTENT TO WHICH A
GIVEN [INDISCERNIBLE] IS
EFFECTED IN ONE CONDITION.
WE CAN SEE IT ALSO MANIFESTED IN
ANOTHER.
IT IS VERY MUCH DEPENDENT IN NOT
JUST ONE FACTOR WHETHER IT
EMERGES AS AN ISOLATED
DESENSITIVITY OF DEPRESSION,
WHICH IS VERY RARE TO HAVE JUST
BY ITSELF OR AS A SEPARATED
ENTITY OF ALCOHOL USE DISORDER
BY ITSELF OR OPIOID USE
DISORDER.
IT IS RATHER A VARIETY OF
FACTORS THAT DETERMINE THE
TRANSITION INTO ONE OR THE
OTHER.
SO IN -- AS WE -- AS WE THINK
ABOUT WHAT ARE THE ISSUES THAT
WE NEED TO PAY ATTENTION TO, I
WOULD WELCOME ALSO THROUGH THIS
MEETING THOUGHTS AND
RECOMMENDATIONS VIS-À-VIS WHAT
ARE SOME OF THE MOST IMPORTANT
AREAS THAT WE NEED TO TRAVERSE
AT THIS POINT IN TIME WHEN WE
ARE OBSERVING, I THINK, FOR THE
FIRST TIME, FORTUNATELY,
RECOGNITION THAT WE NEED TO
ADDRESS CHRONIC DISEASES IN OUR
COUNTRY.
IT SO HAPPENS THAT MOST -- AMONG
THE MOST PERVASIVE CHRONIC
DISEASES ARE SUBSTANCE USE,
INCLUDING MENTAL ILLNESS OR
MENTAL ILLNESS INCLUDING
SUBSTANCE USE.
IF WE CONCEIVE OF MAKE IING THE
HEALTH OF AMERICANS GREAT AGAIN,
WE NEED TO ADDRESS MODELS THAT
WILL BE ABLE TO ACTUALLY PROVIDE
THAT CARE FOR THOSE WITH
SUBSTANCE USE AND MENTAL HEALTH
-- OTHER MENTAL HEALTH
CONDITIONS.
IT IS THIS LINE OF THINKING IN
MY BRAIN, WHICH IS SOMETHING
THAT HAS ALWAYS SORT OF
DISTURBED ME HOW WE SEPARATE
THESE TWO CONDITIONS, GENERATED
MODELS OF CARE THAT ACTUALLY
START BY PROPERLY TRAINING
CLINICIANS TO RECOGNIZE AND TO
TREAT BOTH OF THE CONDITIONS BY
THEMSELVES OR MORE FREQUENTLY AS
THEY OCCUR CO-MORBIDLY BECOMES A
CRUCIAL ONE.
ANOTHER CRUCIAL COMPONENTS I
HOPE THAT WE ARE ABLE TO ADDRESS
THROUGHOUT ALL OF THE
DISCUSSIONS IS WE PAY A LOT OF
ATTENTION ON TREATMENT AS ACUTE
INTERVENTION.
WE NEED TO RECOGNIZE. THIS IS,
AGAIN, FUNDAMENTAL TO HEALTH
ECONOMICS THAT IS NOT JUST ACUTE
PHASE THAT WE NEED TO PAY
ATTENTION TO.
WHAT HAPPENS AFTER THAT ACUTE
PHASE HAS STABILIZED OR WHAT WE
HAVE DESCRIBED VERY MUCH IN THE
SUBSTANCE USE FIELD AS RECOVERY.
SO HOW -- WITHOUT THAT
INVESTMENT IN RECOVERY, THE
ECONOMICS DON'T WORK OUT
PROPERLY. LIKELIHOOD OF PEOPLE
TO SUSTAIN THAT WELLBEING
WITHOUT SUPPORT THAT IS
NECESSARY FOR MANY OF THEM IN
RECOVERY, THEY WILL RELAPSE.
SO I HOPE THAT AS WE GO
THROUGHOUT THE DAY TODAY AND IN
OUR DISCUSSIONS AND PANELS THAT
ISSUE OF HEALTH ECONOMICS AS WE
ARE TARGETING IN TREATMENT
SHOULD ALSO EXPAND INTO
RECOVERY.
I WILL BE AMISSED ALSO IF I --
I REALIZE I WAS CUT OFF. I WILL
COME BACK AND WANT TO END BY
SAYING THAT AS WE GO THROUGH THE
DISCUSSION, LET'S NOT FORGET
ABOUT THE HEALTH ECONOMICS NOT
JUST OF TREATMENT BUT RECOVERY
AND PLEASE LET'S NOT FORGET
ABOUT IMPORTANCE OF HEALTH
ECONOMICS FOR PREVENTION.
IN THE PROCESS AND DIALOGUE WE
WILL CONSIDER CASCADE OF CARE
FROM EARLY PREVENTION TO
TREATMENT ADDRESS ACUTE NEEDS OF
THE INDIVIDUAL AND TO THEN ITS
RECOVERY.
WITH THAT OI WANT TO THANK
EVERYONE FOR PARTICIPATING IN
THE MEETING. I WILL TAKE A TURN
AT THE MICROPHONE BACK TO THE
ORGANIZERS.
THANK YOU.
>> THANK YOU SO MUCH. REALLY
APPRECIATE YOUR SUPPORT FOR THE
HEALTH ECONOMICS MEETING AND
INTRODUCE ANDREA WHO IS ACTING
DIRECTOR OF NIMH WHO WILL
PROVIDE REMARKS FROM THE NIMH
PERSPECTIVE.
>> ANDREA BECKEL-MICHENER , WERE
YOU ABLE TO JOIN?
>> THANK YOU. I COULDN'T HIT
THE CAMERA OR MIC THERE FOR A
MOMENT. I APOLOGIZE.
THANK YOU SO MUCH. I WANT TO
ADD MY EXTENSION OF THE WARM
WELCOME NORA GAVE TO ALL
PARTICIPANTS AND ALSO THANK THE
STAFF AT NIMH AND NIDA AND HEAL
FOR THEIR WORK ORGANIZING THIS
EVENT THIS IS AN INTERESTING
FORUM FOR PARTIES AND
INDIVIDUALS WITH LIVED
EXPERIENCE WITH SUBSTANCE USE
DISORDERS AND SERIOUS MENTAL
ILLNESS TO LEARN ABOUT ADVANCES
AND OPPORTUNITIES AND HEALTH
ECONOMICS RESEARCH.
ALL THINGS NORA SAID REALLY
RESONATED. IT IS A GREAT
EXAMPLE HOW COLLABORATIVE
DISCUSSIONS AND EFFORTS CAN
IDENTIFY OPPORTUNITIES TO LEAD
TO MEANINGFUL BREAKTHROUGHS IN
RELEVANT AREAS OF SCIENCE.
A LITTLE MORE ON HEALTH
ECONOMICS RESEARCH AT NIMH. WE
HAVE COMMITTED TO INVESTMENTS IN
THE ARENA LEADING TO INNOVATIONS
TRANSFORMING MENTAL HEALTH
SERVICES DELIVERY. BACK IN THE
1980S, DR. AGNES DEVELOPED A
PORTFOLIO OF RESEARCH GRANTS TO
STUDY ECONOMIC FEASIBILITY OF
EQUAL COVERAGE FOR MENTAL HEALTH
AND MEDICAL CARE AND PRIVATE
HEALTH INSURANCE PLANS.
THIS BODY OF RESEARCH PROVIDED
ECONOMIC RATIONALE AND
SCIENTIFIC FOUNDATION FOR WHAT
BECAME MENTAL HEALTH PARITY AND
ADDICTION EQUITY ACT OF 2008 AND
REALLY IMPORTANT LEGISLATION
LEADING TO INCREASES IN ACCESS
TO CARE FOR TENS OF THOUSANDS OF
PERSONS WITH MENTAL ILLNESS IN
THE UNITED STATES.
THIS IS A EXAMPLE OF IMPACT OF
THIS TYPE OF RESEARCH.
WE HAVE AN ONGOING COMMITMENT TO
THIS TYPE OF RESEARCH, INCLUDING
A FOCUS ON COMPARING ALTERNATIVE
FINANCING MODELS TO PROMOTE
EFFECTIVE AND EFFICIENT CARE.
ALSO, OVER THE LAST YEAR, NIMH
HAS SUPPORTED INITIATIVES TO
ECONOMIC-BASED RESEARCH
INCLUDING TWO NOTICES OF SPECIAL
INTEREST AND ONE ENCOURAGES
STUDIES OF IMPACT ON POLICY
INTERVENTIONS AIMED AT
ADDRESSING SOCIAL DETERMINANTS
OF HEALTH TO IMPROVE FUNCTIONING
AND WELL-BEING FOR PEOPLE WITH
SERIOUS MENTAL ILLNESSES WHILE
THE OTHER SEEKS RESEARCH ON
IMPACT OF FINANCING AND PAYMENT
MECHANISMS TO IMPROVE BEHAVIORAL
HEALTH ACCESS UTILIZATION AND
OUTCOMES.
HIGH-QUALITY CARE IS ALWAYS A
GOAL AND AS SUCH WE HAVE TO
DEFINE WHAT HIGH QUALITY CARE
MEANS. IN THE PAST YEAR NIMH IS
FUNDED 6 SCALE R01 GRANTS AND
FOUR PILOT R34 GRANTS TO SUPPORT
DEVELOPMENT AND VALIDATION OF
ACCESS MEASURES AND OUTCOME
FOCUSED QUALITY MEASURES IN
MENTAL HEALTH CARE.
FINALLY, THE MOST IMPORTANT
THING IS TO MOVE FROM RESEARCH
TO TREATMENT.
WE FUND RESEARCH TO EXAMINE
INCENTIVES FOR PROVIDERS AND
PAYERS AS WELL AS SOCIOECONOMIC
ISSUES EFFECTING PATIENTS AND
FAMILIES AND RESEARCH CAN HELP
ADDRESS QUESTIONS THAT ARE KEY
TO IMPROVING MENTAL HEALTH
TREATMENT AND SERVICE DELIVERY
AND OUTCOMES INCLUDING
UNDERSTANDING THE BARRIERS,
ECONOMIC BARRIERS, CHALLENGES,
AND OPPORTUNITIES TO PROMOTE
ACCESS TO EVIDENCE-BASED CARE.
WOVEN THROUGHOUT IT IS VITAL TO
ININSIGHTS AND NEEDS OF PEOPLE
WITH LIVED EXPERIENCE TO
IDENTIFY APPROACHES AND HIGHEST
POTENTIAL TO ENHANCE SERVICE
ACCESS AND QUALITY CARE.
SO IN CLOSING, ONCE AGAIN,
THANKS FOR JOINING TODAY AND WE
ARE LOOKING FORWARD TO
CONTINUING TO WORK TOGETHER.
PLEASE FEEL FREE TO ASK
QUESTIONS OF SPEAKERS AND ENGAGE
WITH RESEARCH PRESENTERS.
I'M REALLY LOOKING FORWARD TO
DISCUSSIONS TODAY.
NOW I WILL TURN IT BACK OVER TO
MY COLLEAGUES AT NIMH TO GIVE AN
OVERVIEW OF TODAY'S WORKSHOP.
>> THANK YOU SO MUCH DR.
BECKEL-MICHENER . WE WANT TO
THANK YOU FOR ATTENDING THE
MEETING TODAY AND RESEARCHERS
AND FACILITATORS. THIS
REPRESENTS A COLLABORATION ON
NATIONAL INSTITUTE OF DRUG ABUSE
AND NATIONAL INSTITUTE OF MENTAL
HEALTH THIS IS THE SECOND
MEETING OF THIS TYPE FOLLOWING
FIRST IN 2023 AND GREAT
OPPORTUNITY TO SHOW RESEARCH AND
HEALTH ECONOMICS AND SHOWING --
WE THANK THE HEAL INITIATIVE FOR
SUPPORTING THIS MEETING.
DURING TODAY'S MEETING WE WILL
HAVE FIVE PANELISTS FOCUSING ON
HEALTH ECONOMIC RELATED RESEARCH
AND TREATMENT AND IMPLEMENTATION
APPROACHES AND HEALTH CARE
FINANCING AND DELIVERY MODELS
AND NEEDS AND SPECIAL
POPULATIONS REINTEGRATING MENTAL
HEALTH SUBSTANCE USE AND PRIMARY
CARE AND NEEDS OF PATIENTS AND
FAMILIES AND END OF EACH PANEL
FACILITATORS WILL FACILITATE 15
MINUTE QUESTION AND ANSWER
SECTION. FEEL FREE TO SUBMIT
QUESTIONS TO THE PRESENTERS
THROUGH THE Q & A FUNCTION AND
THERE WILL BE A FEW BREAKS
THROUGHOUT THE DAY THAT ARE
NOTED ON THE SLIDES AND MEETING
IS RECORDED AND AVAILABLE ON NIH
WEBCAST. THERE MAY BE A WEEK
DELAY UNTIL THE MEETING IS
AVAILABLE IN THE PAST SECTION OF
THE EVENT SECTION OF THE NIH
VIDEO CAST AND WE CAN TRANSITION
TO THE FIRST SESSION SHOWCASING
ECONOMIC EVALUATION APPROACHES.
I WILL TURN IT TO OUR FACILITATE
OR.
>> OKAY. IT DOESN'T LOOK LIKE
TEAMS IS LETTING ME TURN ON MY
CAMERA NOW.
IT WORKED A MOMENT AGO.
HOPEFULLY YOU CAN ALL HEAR ME?
>> YES.
>> GREAT. GOOD MORNING EVERYONE
I'M ERIKA CRABLE AND WE WILL
START THE WORKSHOP COVERING A
SUPER IMPORTANT TOPIC, HOW TO
USE DIFFERENT ECONOMIC
EVALUATION APPROACHES TO PROMOTE
IMPLEMENTATION, SUSTAINMENT AND
SCALE-UP FOR EFFECTIVE --
ECONOMIC BARRIERS ARE CONSIDERED
LATE IN THE GAME AS A REASON TO
NOT SUSTAIN EVIDENCE-BASED
PRACTICE BEYOND A RESEARCH
TRIAL.
WE WILL CHANGE COLLECTIVE
THINKING AND FUTURE ACTIONS
TODAY AND TOGETHER WE WILL LEARN
ABOUT DIFFERENT ECONOMIC
EVALUATION APPROACHES, TOOLS AND
WAYS TO ENGAGE DECISION MAKERS
SO WE IDENTIFY ECONOMICALLY
FEASIBLE EVIDENCE-BASED
PRACTICES AND ECONOMICALLY
FEASIBLE IMPLEMENTATION
STRATEGIES LEADING TO LONG-TERM
SUSTAINMENT. WE NEED DURABLE
RESULTS NOT JUST IMPLEMENTATION
EFFORTS WORKING UNDER
WELL-FUNDED RESEARCH CONDITIONS.
AS WE BEGIN THE PANEL USE THE Q
& A BOX TO SHARE QUESTIONS YOU
HAVE AT ANY TYPE. WE WILL
COLLECT QUESTIONS AND RESPOND
AFTER ALL OUR PRESENTATIONS IN
THE FIRST PANEL HAVE FINISHED
AND WILL KICK OFF A DISCUSSION
ABOUT A PRESENTATION ABOUT A
COOL CUSTOMIZED ECONOMIC
MODELING TOOL DAVID SMELSON FROM
UMASS MEDICAL SCHOOL AND TODD
OLMSTEAD CREATED WITH MASS
HEALTH MASSACHUSETTS AID AGENCY.
I WILL HAND IT TO THEM.
>> THANK YOU FOR THE OPPORTUNITY
TO PRESENT TODAY. MAKING SURE
TODD HAS CONTROL OF THE SLIDES.
>> YES.
>> PERFECT. THANK YOU SO MUCH.
MY NAME IS DAVID SMELSON IN THE
DEPARTMENT OF MEDICINE AT U MASS
MEDICAL SCHOOL AND PRESENTING
TODAY WITH TODD WHO IS IN
DEPARTMENT OF HEALTH AND
ECONOMIC HEALTH AT CORNELL
UNIVERSITY.
THANK YOU TO THE NIH FOR GENERAL
FUNDING ABOUT WORK WE WILL TALK
ABOUT TODAY AND I RECEIVED
FUNDING FROM NIDA AND NIMH AND
TODD RECEIVES FUNDING FROM NIMH
NIDA AND NIMH LBA NEXT SLIDE I
WILL GIVE AN OVERVIEW OF A
MULTICOMPONENT INTERVENTION WE
ARE STUDYING THROUGH HEAL
INITIATIVE CALLED MISSION TO
ADDRESS ADDICTION AND MENTAL
HEALTH AND IN THIS PARTICULAR
CASE OPIOID USE DISORDER AND I
WILL TALK ABOUT THE MEDICAID
BILLING PROCESS WE WENT THROUGH
FOR REIMBURSEMENT AND
SUSTAINABILITY AND TODD WILL
TALK ABOUT PLANNED ECONOMIC
ANALYSIS AND DOING THAT ALL IN
10 MINUTES .
THANK YOU. MISSIONS AND
MULTICOMPONENT COLLABORATIVE
CARE DEFINES THREE
EVIDENCE-BASED PRACTICES
A BUNCH OF EVIDENCE WITHIN THE
PRACTICES THAT WE INTEGRATED IN
A SYSTEMATIC WAY AND THOSE
PRACTICES ARE CRITICAL TIME
INTERVENTION DUAL RECOVERY AND
PEER SUPPORT AND IN THE NEXT FEW
SLIDES I WILL GIVE A BRIEF
OVERVIEW WHAT THE INTERVENTION
FEELS LIKE AND WANT TO SAY THAT
IT FOCUSES ON HARM REDUCTION
PHILOSOPHY AND IS A TEAM-BASED
MODEL AND CASE MANAGER AND PR
TEAM THAT DELIVERS SERVICES
APPROXIMATELY 20 CLIENTS PER
TEAM AND HIGH MODEL AND
TREATMENT LENGTH IS 6 TO 12
MONTHS AND IN THIS PARTICULAR
CASE STUDYING 6-MONTH
INTERVENTION.
NEXT SLIDE, PLEASE.
SO WHOOPS. ONE BEFORE. THANKS.
THE FIRST EVIDENCE-BASED
COMPONENT IS CRITICAL TIME
INTERVENTION AND TIME-LIMITED
FORM OF CASE MANAGEMENT. FOCUS
IS REALLY ON LINKING PEOPLE TO
COMMUNITY-BASED CARE AND
PROVIDING RECOVERY SUPPORTS AND
MISSION IS TIME-LIMITED
INTERVENTION AND WANT TO HELP
PEOPLE ENGAGE IN THE COMMUNITY
AND IS REALLY THE FIRST STAGE
AND FOCUS AT THE BEGINNING.
IT GETS LESS INTENSIVE OVER TIME
AND TRYING OUT SERVICES IN THE
COMMUNITY AND MAKING ADJUSTMENTS
AND TRANSFERRING CARE BECAUSE AT
THE END 6 MONTHS TREATMENT IS
OVER.
AGAIN, IT FOLLOWS A STEP-DOWN
APPROACH THAT IS DELIVERED BY
CASE MANAGER AND PEER THAT DO
SLIGHTLY DIFFERENT THINGS AND
CASE MANAGER MIGHT FOCUS ON
LINKING PEOPLE TO TRADITIONAL
HEALTH CARE SETTINGS AND PEER
MIGHT FOCUS ON 12-STEP THERAPY
AND OTHER RECOVERY ACTIVITIES.
NEXT SLIDE.
SECOND COMPONENT IS INTEGRATED
-- 13 GROUP SESSIONS THAT FOCUS
ON THE INTEGRATION OF MENTAL
HEALTH AND SUBSTANCE ABUSE AND
THEY ARE MOTIVATION BASED CBT
AND RELAPSE PREVENTION DELIVERED
BY CASE MANAGER AND EACH OF THE
SESSIONS HAS WORKSHEETS
ASSOCIATED WITH IT. IT IS A
PRETTY STRUCTURED INTERVENTION.
NEXT SLIDE, PLEASE.
THIRD COMPONENT IS PEER SUPPORT
MENTIONING BEFORE PEERS DO A
SORT OF COMMUNITY OUTREACH THAT
ALSO RUN STRUCTURED GROUPS THAT
WERE DEVELOPED BY PEERS FOR
PEERS AND THERE ARE 11
STRUCTURED SESSIONS THAT AGAIN
FOLLOW THE SAME FORMAT WITH DRT
WITH WORKSHEETS AS PART OF THE
SERVICE DELIVERY.
NEXT SLIDE.
JUST A SECOND ABOUT OUTCOMES.
SO, AGAIN, THERE IS A LOT OF
EVIDENCE BEHIND COMPONENTS THAT
WE HAVE INTEGRATED AND MISSION
ITSELF IN STUDIES WE HAVE SHOWED
IMPROVEMENT TO HEALTH SYMPTOMS
AND FUNCTIONING AND REDUCTION
AND SUBSTANCE USE AND IMPROVING
HEALTH OUTCOMES REDUCTION AND
REHOSPITALIZATIONS AND WE HAVE
HIGH ENGAGEMENT RATES BETWEEN 75
AND 80% AT 6 MONTHS AND
INCREASED ACCESS ENGAGEMENT AND
MITIGATION FOR OPIOID USE
DISORDER AND ALCOHOL USE
DISORDER AND MENTAL HEALTH.
NEXT SLIDE?
PLEASE.
NEXT SLIDE?
MIGHT BE STUCK.
>> I'M TRYING.
>> IT IS OKAY.
>> NOT LETTING ME ADVANCE.
>> TECHNOLOGY.
THAT IS NOT GREAT.
>> THERE WE GO.
>> TOO FAR. HANG ON.
>> THERE WE GO.
>> I'M SORRY.
>> DON'T WORRY. DON'T WORRY.
JUST TO SAVE IT, STAFF USED A
TREATMENT MANUAL TO DELIVER
MISSION TO INCREASE FIDELITY AND
EACH CLIENT GETS A WORKBOOK WITH
EXERCISED DIMENSION.
NEXT SLIDE, PLEASE.
QUESTION WITH MULTICOMPONENT
INTERVENTION APPRECIATING NORA'S
COMMENT IN THE BEGINNING AND
COSTS TO HAVE SCALE AND SUSTAIN
INTERVENTIONS AND WE STARTED TO
WORK WITH LOCAL MEDICAID
AUTHORITY THATS WITH A GREAT
PARTNER FOR US TO TRY TO FIGURE
OUT HOW TO GET REIMBURSE FORD
ALL COMPONENTS OF MISSION.
WE REALLY WANTED TO FIGURE OUT
NOT ONLY THE CORE COMPONENTS BUT
IF ANY OTHER SERVICES HOW TO GET
REIMBURSED FOR THAT AND YOU CAN
SEE ON THIS SLIDE IS ALL
REIMBURSEMENT CODES WE
COLLABORATIVELY CAME UP WITH AND
UNIT RAITY FOR MASSACHUSETTS
THAT -- THAT THEY REIMBURSED AT.
NEXT SLIDE.
SO THE OTHER QUESTION WITH
MULTICOMPONENT INTERVENTION IS
SLIDE BEFORE THAT, TODD.
THANKS.
IT IS REALLY HOW PROGRAMS WILL
OFFER -- IT IS A BIG INVESTMENT
TO HIRE TWO STAFF AND HAVE THEM
THINK ABOUT HOW TO MAKE INITIAL
INVESTMENT. WE WORK WITH A LOT
OF SOLUTIONS TO DEVELOP A
CUSTOMIZED MODELING TOOL WHERE
YOU CAN THINK ABOUT THINGS LIKE
CASE LOAD SIZES AND IF YOU
WANTED HIGHER OR LOWER CASE LOAD
SIZES OR SERVICE ENGAGEMENT WHAT
YOU ARE PREDICTING FOR YOUR
CLIENTS AND STAFF. THAT WOULD
HELP YOU DETERMINE REVENUE YOU
WOULD GENERATE. THAT IS PROVEN
TO BE AN ACTUALLY VERY HELPFUL
TOOL FOR US AND TODD WILL TURN
IT OVER YOU TO AND YOU WILL TALK
ABOUT THE REVENUE AS WELL AS
COST ANALYSIS.
THANK YOU SO MUCH FOR LISTENING.
>> THANK YOU, DAVID. EXCEL
MODELING POOL DAVID SHARES HAS
REALLY COOL FEATURES INCLUDING
ABILITY TO HAVE NET PROFIT FOR
EXAMPLE 6 MONTHS IMPLEMENTATION
WITH MISSION OF FULL FIDELITY WE
PROJECT GROSS CLINIC CAL REVENUE
IS $270,000 AND NETTING OUT
FULLY LOADED STAFFING COST NET
PROFIT OF $177,000 THAT IS GREAT
AND YOU CAN TELL HERE MISSION IS
NOT EXACTLY CHEAP AND REMAINS A
QUESTION WHETHER IT IS POSSIBLE
TO GET MORE VALUE OUT OF MISSION
AND 2 OUT OF 3 OF ITS PARTS
INSTEAD OF USING ALL THREE
COMPONENTS.
IN THIS WHICH 2 PARTS SHOULD BE
BUNDLED TOGETHER TO GET MOST
VALUE AND BRINGING US TO CURRENT
STUDY DESCRIBING NEXT ALONG WITH
PLANNED ECONOMIC ANALYSIS AND
STUDY IS RANDOMIZED CONTROL
TRIAL AND OPIOID USE AND MENTAL
HEALTH DISORDERS RECEIVING
MEDICATION FOR OPIOID USE
DISORDER.
WE HAVE FIVE STUDY ARMS AND
FIRST ARM IS MOUD ALL BY ITSELF
AND SECOND ARM IS FULL-MROEN
MISSION ALONG WITH MOUD AND LAST
THREE STUDY ARMS IS DIFFERENT
WAYS COMBINING 2 OUT OF 3 PARTS
MISSION ALONG WITH MOUD AND WE
ARE RECRUITING FROM OUTPATIENT
CLINICS IN SUPPORT PROGRAMS AND
GOAL IS TO RECRUIT 1,000 PASH
YOERNTS WITH 2 HUNDRED
RANDOMIZED EACH CONDITION AND
THESE TAKE PLACE AT BASELINE AND
QUARTERLY THEREAFTER FOR ARY AND
HIGH-LEVEL DESCRIPTION OF A
STUDY AND I WILL TALK YOU TO FOR
A MINUTE ABOUT PLANNED ECONOMIC
ANALYSIS.
FOR SHORT WE WILL USE
TRADITIONAL COST EFFECTIVE
ANALYSIS SPECIFICALLY TO COMPARE
5 ARMS WE USE INCREMENTAL COST
EFFECTIVENESS RATIOS DEFINED AS
INCREMENTAL COST OF GIVEN
TREATMENT AND COMPARED TO NEXT
TREATMENT AND PAINTING
ADDITIONAL UNIT OUTCOME AND
[INDISCERNIBLE] AND ADDITIONAL
DEPRESSION FREE DAY AND SO ON.
NOW THIS IS POINT ESTIMATES YOU
CAN THINK OF AS SINGLE BEST
GUESS AND RELATIVE COST
EFFECTIVENESS OF STUDY
INTERVENTIONS AND DECISION
MAKERS WE WILL GO FURTHER TO
PROVIDE DECISION MAKERS WITH A
SENSE OF STATISTICAL UNCERTAINTY
BEHIND OUR POINT ESTIMATES WILL
ALSO PROVIDE 95% COST INTERVALS
AND COST EFFECTIVENESS
SUSCEPTIBILITY CURVES IF YOU
HAVE NOT HEARD OF THEM NICE
INTUITIVE VISUAL TOOL TO
SEPARATE REPORTING COST
EFFECTIVENESS ANALYSIS AND FOR
EXAMPLE EACH INTERVENTION
SHOWING PROBABILITY OF Y AXIS 0
AND 1 AND EACH INTERVENTION IS
COST EFFECTIVE COMPARED TO
OTHERS IN THE STUDY FOR RANGE OF
DOLLAR VALUES HERE ON X AXIS AND
RANGE OF DOLLAR VALUES DECISION
MAKER IS WILLING TO PAY FOR
ADDITIONAL UNIT OF OUTCOME AND
WE WILL CALCULATE THESE AND
ACCEPTABILITY CURVES FROM
VARIETY OF PERSPECTIVES THAT IS
VERY IMPORTANT WHEN CONDUCTING
ECONOMIC EVALUATION AND I'M SURE
WE WILL HEAR FROM OTHER
PANELISTS THROUGHOUT THE DAY AND
WHY IS THIS IMPORTANT?
PERSPECTIVE LITERALLY DEFINES
WHAT IS COST AND BENEFIT AND
TRANSFER AND SO ON AND ECONOMIC
EVALUATION AND FOLLOWING
RECOMMENDATIONS ON SECOND PANEL
WILL INCLUDE SOCIETAL AND HEALTH
CARE SYSTEM PERSPECTIVES IN
ANALYSIS IN ADDITION TO MAKE
SURE RESULTS ARE MAXIMAL USEFUL
TO WIDE RANGE OF DECISION MAKERS
CONDUCTING ANALYSIS FROM PATIENT
CLINIC AND TAXPAYER PERSPECTIVES
AND RATIONALE FOR THESE
ADDITIONAL PERSPECTIVES IS
PATIENTS DETERMINE WHETHER TO
ACCEPT TREATMENT BASED IN PART
ON TIME ON TREATMENT AND
TRANSPORTATION TIME AND COPAYS
AND CLINICS DETERMINE WHETHER TO
ADOPT TREATMENT AT LEAST IN PART
ON SUSTAINABILITY AND RETURN ON
INVESTMENT FOR EXAMPLE
OFFSETTING IMPLEMENTATION COSTS
AND TAXPAYERS AND GOVERNMENT ON
BEHALF TREATMENTS ON REDUCTIONS
AND MEDICAID EXPENDITURES
CRIMINAL JUSTICE SYSTEM AND SO
ON.
FINALLY WE WILL CONDUCT
SENSITIVITY ANALYSIS TO SHOW HOW
ROBUST ANALYSIS IS AND UNIT COST
AND ALTERNATIVE IMPLEMENTATION
SCENARIOS.
ALL RIGHT. NOW, OUTCOMES AND
RUMOR OUTCOMES DENOMINATOR OF
COST RATIOS AND OUTCOMES LOOKING
AT QUALITY LIFE YEARS PATIENT
ENGAGEMENT OPIOID USE AND MENTAL
HEALTH.
USING MULTIPLE OUTCOMES
DETERMINE ROBUSTNESS OF FINDINGS
AND FINE-GRAINED ECONOMIC
ANALYSIS TO ADDRESS DECISION
MAKING PRIORITIES.
FINALLY, ON COST SIDE OF THINGS,
WE WILL BE ESTIMATED
IMPLEMENTATION COSTS INCLUDING
ALL RESOURCES REQUIRED TO BOTH
START-UP AND CONTINUE DELIVERING
EACH OF THE INTERVENTIONS
MEASURING COST OFFSETS HEALTH
UTILIZATION MEDICATIONS ACTIVITY
AND REPORTING THINGS LIKE
EARNINGS MISSED DAYS AT WORK IN
OFFICE AND HOME AND MENTAL
HEALTH SUBSTANCE ABUSE DISORDERS
AND LEGAL ISSUES INTERACTIONS
WITH THE CRIMINAL JUSTICE SYSTEM
AND THE DATA TO MEASURE COST
SIDE OF THINGS COMING FROM A
VARIETY OF DIFFERENT SOURCES
STUDY INVOICES PARTICIPANT
SURVEYS AND [INDISCERNIBLE].
THAT CONCLUDES A HIGH-LEVEL
SUMMARY OF STUDY AND ECONOMIC
ANALYSIS WE HAVE PLANNED AND THE
DEVIL IS REALLY IN THE DETAILS I
WOULD BE HAPPY TO TALK ABOUT
AFTERWARDS. IF YOU WANT TO GET
INTO NITTY GRITTY FEEL FREE TO
SEND ME AN E-MAIL I'M AT CORNELL
PUBLIC HEALTH AND CORNELL'S
POLICY CENTER.
WITH THAT, BACK OVER.
>> THANK YOU SO MUCH. NEXT
SPEAKER IS FREYA NEZIR FROM
UNIVERSITY OF PENNSYLVANIA
HIGHLIGHTING VARIETY OF ECONOMIC
APPROACHES SUPPORTING REAL WORLD
SCALE UP OF ECONOMIC BEST
PRACTICES.
TAKE IT AWAY.
WE CANNOT HEAR YOU. MIGHT NEED
TO UNMUTE.
>> I WAS ABLE TO DELETE THAT.
GOOD MORNING, EVERYONE.
I'M FREYA NEZIR AND PLEASURE TO
BE HERE AND CONTRIBUTE TO THIS
WORKSHOP.
TODAY I WILL TALK ABOUT THE
PROMISE OF COLLABORATIVE CARE
FOR PEOPLE WITH OPIOID USE AND
MENTAL HEALTH DISORDERS AND
ECONOMIC TOOLS AND SUPPORT THAT
IS NEEDED TO MAKE IT WORK IN THE
REAL WORLD.
BEFORE WE DIVE IN, QUICK NOTE
HOW I USE THE TERM ECONOMIC
EVALUATION.
IN OUR FIELD IT MEANS FORMAL
STUDIES COMPARING COST OUTCOMES
COST EFFECTIVENESS OR COST
BENEFIT ANALYSIS HERE I'M USING
IT BROADLY COST FINANCING
STRATEGIES AND RESOURCE PLANNING
WAND THAT IN MIND LET'S TURN TO
COLLABORATIVE CARE.
NEXT SLIDE, PLEASE.
BIG PICTURE COLLABORATIVE CARE
IS CLINICALLY EFFECTIVE BUT
UNDERUSED.
DO WE BREAK EVEN? MOST
EVALUATIONS DON'T ANSWER THOSE.
SO THE GAP IS NOT IN EVIDENCE.
IT IS IN THE INFRASTRUCTURE THAT
IS NEED TODAY MAKE MODELS
SUSTAINABLE.
NEXT SLIDE, PLEASE.
SLIDE 3. A QUICK OVERVIEW AND
COLLABORATIVE CARE STRUCTURE
TEAM-BASED MODEL AND PRIMARY
CARE PROVIDER BEHAVIORAL HEALTH
MANAGER AND PSYCHIATRIC KWON
SULTANT ON SHARED CASES
COORDINATED MEASUREMENT-BASED
REGULARLY REVEALING PROGRESS
TRACKING AND ACCOUNTABILITY AND
DESIGNED FOR DEPRESSION IT IS
ADAPTED FOR OUDC PTAC AND OTHER
CONDITIONS.
NEXT SLIDE, PLEASE.
WHY IT MATTERS FOR OUR SPECIFIC
POPULATION, IT IS KEY FOR
SPECIFIC POPULATION WITH WHICH
OFTEN CALLED CURE MENTAL HEALTH
DISORDERS OCCUR TOGETHER 60 TO
80% THOSE WITH THIS HAVE MENTAL
HEALTH DIAGNOSIS BUT TREAT THESE
CONDITIONS SEPARATELY RELAPSE
AND OVERDOSE AND COLLABORATIVE
CARE BRINGS PHYSICAL MENTAL AND
ADDICTION TREATMENT TO ONE
COORDINATED SYSTEM WITH CLEAR
ROLES AND SHARED PLANS AND BROAD
OVERSIGHT.
NEXT SLIDE, PLEASE.
CLINICAL EVIDENCE KEEPS GROWING
COLLABORATIVE CARE IMPROVES
PSYCHIATRIC SYMPTOMS CARE
ENGAGEMENT RETENTION FOLLOW UP
CARE CONTINUITY AND MEDICATION
ADHERENCE HELPING REDUCE
SUBSTANCE ABUSE RELAPSE OVERDOSE
RISK AND HOSPITAL AND ED VISIT
AND EMERGENCY DEPARTMENT VISIT
AND SOME OF THE RESULTS ARE IN
DEPRESSION.
AND MEDICATION-ASSISTED
TREATMENT AND SUPPORT FOR
BROADER CO-OCCURRING CONDITIONS
IS EXPANDING.
NEXT SLIDE, PLEASE.
STRONG ECONOMIC VALUE AS WELL,
STUDIES SHOW 3,000 TO 7,000 IN
ANNUAL SAVINGS PER PATIENT
MOSTLY FROM FEWER ED AND PATIENT
VISITS AND SOME STUDY REPORTS
RETURN AS HIGH AS ALMOST $6 PER
1 DOLLAR INVESTED AND SYSTEMWIDE
BENEFITS ACROSS MANY SIDES.
HERE IS THE KEY.
FINDINGS HAVEN'T BECOME USABLE
TOOLS FOR DECISION MAKERS AND
GIVE US DATA EVIDENCE AND NOT
ANSWERS THAT PEOPLE NEED LIKE
WHEN DO WE BREAK EVEN OR HOW DO
COSTS CHANGE OVER TIME?
NEXT SLIDE, PLEASE.
SO WHAT DO CURRENTLY SUCH
ECONOMIC STUDIES OFFER?
MOSTLY RESEARCH-FOCUSED MODELS
NOT TOOLS FOR REAL-WORLD
DECISIONS AND WE SEE OFTEN COST
EFFECTIVENESS AND DOLLAR PER
COLLY COST BENEFIT ANALYSIS
RETURN PER DOLLAR BUDGET IMPACT
ANALYSIS SHORT TERM
AFFORDABILITY AND DESCRIPTIVE
COST ANALYSIS SIDE ENCOUNTER
LEVEL COST ESTIMATES THAT GIVE
BOTH INSIGHTS BUT RARELY GUIDE
SIGHT LEVEL AND SPECIFIC SYSTEM
LEVEL PLANNING.
NEXT SLIDE, PLEASE.
SO THE GAPS ARE NOT -- THESE
GAPS ARE CLEAR, TRIAL DATA THAT
DON'T TRANSLATE LOCALLY. NO
GUIDANCE ON STAFFING, FUNDING OR
BILLING.
OUTPUTS THAT ARE NOT BUILT FOR
REAL-WORLD USE.
LONG-TIME STUDIES WITH LITTLE
FOCUS ON SUSTAINABILITY AND
SCALE-UP.
NEXT SLIDE, PLEASE.
THESE GAPS ARE NOT UNIQUE TO
COLLABORATIVE CARE.
THEY ARE TOUGHER TO SOLVE
BECAUSE THE MODEL ITSELF IS
COMPLEX.
IT INVOLVES MULTIPLE STAFFING
WITH DIFFERENT BILLING AND
MULTIPLE CONDITIONS WITH SHARED
COSTS AND OUTCOMES AND
FRAGMENTED FUNDING ACROSS
SYSTEMS AND DIFFERENT FINANCIAL
PHASES THAT START-UP
IMPLEMENTATION SUSTAINMENT
MISALIGNED INCENTIVES, COMPLEX
CPT BILLING AND COORDINATION
ACROSS CLINICAL AND FINANCIAL
TEAMS.
NEXT SLIDE, PLEASE.
SO WHAT DO DECISION MAKERS NEED
FOR REAL-WORLD DECISIONS?
THEY NEED TOOLS THAT MATCH REAL
DECISIONS.
FOR ADOPTION, BREAK EVEN AND
RETURN ON INVESTMENT
CALCULATORS.
FOR PLANNING, STAFFING MODELS
BUDGET PAMPHLETS AND SALARY TO
PATIENT RATIOS. IMPLEMENTATION
BILLING MAPPERS LINK TO
WORKFLOWS AND CPT CODES AND
SUSTAINMENT MULTI-YEAR BUDGET
TRACKERS CASH FLOW TOOLS SCALE
UP RETURN ON INVESTMENT
DASHBOARDS AND FLEXIBLE SCENARIO
PLANNERS.
NEXT SLIDE, PLEASE.
SO THESE ARE EXAMPLES OF THE
TOOLS THAT WE SHOULD BE
BUILDING.
LOCAL COST TEMPLATES FOR
BUDGETING AND FORECASTING AND
BREAKEVEN CALCULATORS TIED TO
SALARY AND PAYER MIX.
SCENARIO PLANNERS FOR SCALING
AND STAFFING.
BILLING MAPPERS LINKED TO CPT
CODES AND FINANCING VISUALIZERS
FOR BRAIDED FUNDING AND
DASHBOARDS COMPARING
COLLABORATIVE CARE TO OTHER
MODELS AND DECISION TREES FOR
SIGHT-LEVEL SYSTEM LEVEL
GUIDANCE AND TOOLKITS WITH
TRAINING, RESOURCES AND EXPERT
SUPPORT.
THESE ARE TOOLS FOR ACTION NOT
JUST JOURNAL PUBLICATION.
NEXT SLIDE, PLEASE.
MOST IN THE GROUP CAN'T BUILD
THIS ALONE.
THIS IS WHAT EACH ROLE CAN DO.
ECONOMIC EVALUATORS AND
CO-DESIGNED TOOLS WITHEND USERS
FOCUS ON PRACTICAL TOOLS AND
IMPLEMENTERS ASK FOR TOOLS AND
SHARE LOCAL DATA AND PLAN FOR
SUSTAINABILITY.
FUNDERS SUPPORT TOOL BUILDING
NOT JUST TRIALS THAT REQUIRE
ECONOMIC PLANNING.
POLICY MAKERS AND PAYERS SET
SUSTAINABLE GOALS ALIGNING
FUNDING WITH INTEGRATED CARE.
I THINK THAT IS HOW WE START TO
BUILD THIS INFRASTRUCTURE TO
TURN PROVEN MODELS INTO
REAL-WORLD PRACTICE.
NEXT SLIDE.
TO WRAP UP, COLLABORATIVE CARE
DELIVERS REAL CLINICAL AND
ECONOMIC VALUE.
BUT UPTICK IS SLOW AND SEEMS NOT
BECAUSE IT DOESN'T WORK BUT
BECAUSE ECONOMIC INFRASTRUCTURE
IS MISSING AND WHAT WE NEED ARE
PRACTICAL DECISION RELATED TOOLS
TO TURN EVIDENCE INTO ACTION.
THANK YOU.
>> THANK YOU, DR. NEZIR I
APPRECIATE THE NEW CALL TO
ACTION BILL.
NEXT SPEAKER IS LISA SALDANA
FROM CHESTNUT HEALTH SYSTEMS
INSTITUTE AND STRATEGIES THAT IS
CRITICAL TO FEASIBILITY AND
SUSTAINMENT CONSIDERATION AND
WILL SHOW YOU EXCEPTIONALLY
USEFUL COINS TOOL THAT HELPS
WITH DIRECT AND INDIRECT COSTS.
>> HELLO. GOOD MORNING. CAN
YOU HEAR ME?
>> WE CAN HEAR YOU.
>> GREAT. THANK YOU. I DON'T
BELIEVE I HAVE CONTROL OF THE
SLIDES YET.
THERE WE GO.
LET SEE IF I CAN ADVANCE. NOT
QUITE YET.
ABOUT THE IMPORTANCE OF COSTING
IMPLEMENTATION STRATEGIES.
THOSE ARE THE STRATEGIES WE
ACTUALLY USE TO MOVE THESE GREAT
INTERVENTIONS INTO PRACTICE.
AND TO TALK A LITTLE BIT ABOUT A
TOOL THAT WE USE TO COLLECT THAT
DATA THAT THEN INFORMS ECONOMIC
ANALYSIS.
BEFORE I GET STARTED I WANT TO
ACKNOWLEDGE THAT MUCH WORK WITH
THE COINS TOOL WAS DEVELOPED
ALONGSIDE STAGES OF
IMPLEMENTATION COMPLETION DURING
MY TIME WHEN I WAS AN EMPLOYEE
WITH OREGON SOCIAL LEARNING
CENTER WHO OWNS THE TRADEMARK TO
THIS AND STARTING TYPES OF TALKS
OUT WITH A DISCLAIMER AND I'M
NOT AN ECONOMIST FOR THOSE THAT
KNOW ME I'M AN IMPLEMENTATION
SCIENTIST AND CLINICAL
PSYCHOLOGIST AND WHAT I REALLY
DO IS EVERYTHING -- ALL RESEARCH
I DO CENTERS AND SITS ON
IMPORTANT VALUE OF ECONOMICS AND
BEING ABLE TO AFFORD ALL OF THE
GREAT INNOVATIONS THAT WE KNOW
WE WANT TO GET INTO THE HANDS OF
CONSUMERS.
TO BEGIN WITH, I ALSO WANT TO
JUST SORT OF SIT WEIGHT US TO
THE FACT AS I MENTIONED AS AN
IMPLEMENTATION SCIENTIST WE
ALWAYS START WITH AN
IMPLEMENTATION FRAMEWORK AND
THIS IS FOR THOSE WHO ARE --
MANY OF YOU ARE PROBABLY
FAMILIAR WITH, THIS IS LAURA AND
COLLEAGUES AND WHAT WE CALL THE
C FOR MODEL WHICH IS A
CONSOLIDATED FRAMEWORK OF
IMPLEMENTATION RESEARCH THAT IS
A WIDELY USED MODEL AND POINT
BRINGING IT UP HERE IS WE SEE
ALL THESE DIFFERENT COMPONENTS
GOING INTO LOOKING AT
IMPLEMENTATION AND
IMPLEMENTATION FRAMEWORK.
WHEN WE ARE TYPICALLY TALKING
ABOUT COSTS AND COSTING
LITERATURE THAT REALLY FOCUSED
ON COST OF INTERORIGINAL
INTERVENTION OR ADAPTED
INTERVENTION IS WHERE FOLKS ARE
REALLY FOCUSED AND WE CONSIDER
THE INTERVENTION TO BE SORT OF
THE THING. THE THING WE ARE
TRYING TO IMPLEMENT.
WHAT I WILL TALK ABOUT TODAY IS
INSTEAD ON THE PROCESS.
OOPS.
SO THE PROCESS REALLY IS THE
UNDERLYING STRUCTURE. THIS IS
WHAT MOVES YOUR -- MOVES YOUR
INTERVENTION FROM A TO B AND
MOVES IT FROM AN IDEA AND
GETTING IT INTO PRACTICE.
THAT IS AN ESSENTIAL PART OF
COSTING THAT IS OFTEN TIMES
IGNORED AND IMPLEMENTATION
PROCESS IS AROUND ESSENTIAL PART
THINKING ABOUT WITH
IMPLEMENTATION.
THIS IS REALLY THE STEPS AND
SEQUENTIAL PACING THAT WE THINK
ABOUT IN TERMS OF HOW WE DO THE
ACTIVE IMPLEMENTING.
SO IT IS ONE THING TO HAVE
AMAZING INTERVENTIONS DEVELOPING
THESE THINGS WITH HEAL AND
DEVELOPING REALLY GREAT
PREVENTIVE INTERVENTIONS AND
RECOVERY SORT OF INTERVENTIONS
BUT WANTING TO REALLY THINK
ABOUT MOVING THESE INTO ACTION
WE WANT TO THINK ABOUT WHAT ARE
STEPS?
IN EACH OF THE STEPS ARE
STRATEGIES WE WANT TO CONSIDER.
THOSE -- I LOST CONTROL AGAIN
AND STRATEGIES THAT WE REFERRED
TO IS IMPLEMENTATION STRATEGIES
THAT ARE REALLY THE HOW OF
IMPLEMENTATION.
WHEN WE THINK ABOUT HOW, SO
THESE STEPS AND STRATEGIES THAT
WE ARE FOLLOWING, WE ALSO WANT
TO CONSIDER ESPECIALLY WHEN
THINKING ABOUT COSTS AND WHO THE
ACTOR IS AND WHO IS DOG THIS AND
SOMEBODY THAT IS AN EXECUTIVE
LEADER THAT OF COURSE HAS A ONE
THICK TYPE OF SALARY AND
SOMEBODY THAT IS AN
ADMINISTRATIVE ASSISTANT THAT IS
A DIFFERENT TYPE OF SALARY OR
VOLUNTEER THAT MIGHT NOT HAVE
ANY SALARY AT ALL AND THINKING
ABOUT HOW COMPLICATED THE THING
IS THAT IS BEING IMPLEMENTED AND
SOMETHING WHERE IT IS A 15
MINUTE EXERCISE ROUTINE FOR
OBESITY TYPES OF STUDIES AND IS
IT SOMETHING THAT WILL BE A VERY
COMPLEX INTERVENTION SUCH AS
MANY OF THE INTERVENTIONS BOTH
PREVENTIVE AND TREATMENT
INTERVENTIONS WE HAVE FOR
TREATMENT OF OPIOID USE AND WE
WANT TO ALSO THINK ABOUT WHO IS
BEING SERVED BY THIS AND IN THE
CONTEXT THAT IS VERY DIFFERENT
TO IMPLEMENT SOMETHING IN HIGH
RESOURCED VERSUS UNDERRESOURCED
ENVIRONMENT.
WHEN WE DO THAT WE THINK OF
IMPLEMENTATION PROCESS AND ONE
OF THE MOST UBIQUITOUS
IMPLEMENTATION PROCESS
FRAMEWORKS OUT THERE IS FS AND
GREG AND COLLEAGUES STANDING FOR
EXPLORATION PREPARATION
IMPLEMENTATION AND SUSTAINMENT
IS A FRAMEWORK THAT HAS BEEN
USED BY HUNDREDS OF DIFFERENT
RESEARCHERS BUT THEN ALSO REAL
WORLD IMPLEMENTERS WHO ARE
TRYING TO UNDERSTAND WHAT ARE --
WHAT DO THEY -- WHAT ARE PHASES
THEY HAVE TO GO THROUGH WHEN
THEY DECIDE WHEN THEY WANT TO
IMPLEMENT A NEW INTERVENTION.
THIS FRAMEWORK MAPS WELL ON TO
THE WORK THAT MY COLLEAGUES AND
I HAVE DONE WITH STAGES OF
IMPLEMENTATION COMPLETION OR
SICK AND SICK IS A MEASURE OF
IMPLEMENTATION PROCESS THAT CAN
ALSO BE USED AS A MODEL OF
IMPLEMENTATION.
AND SO WHAT IT REALLY DOES IS IT
-- IT IS 8 STAGES.
THESE 8 STAGES OF IMPLEMENTATION
YOU CAN SEE SORT OF MAP ON TO
THIS FRAMEWORK THAT IS, AGAIN,
THAT PROCESS FRAMEWORK AND WHAT
WE THINK ABOUT IS THE FIRST
THREE STAGES THAT IS LIKE
ENGAGING AND DECIDE WLG OR NOT
YOU WANT TO DO THIS THING AND
DETERMINING WHETHER IT IS
FEASIBLE AND PREPARING YOUR
AGENCY OR ORGANIZATION TO DO IT
AND WE REFER TO THAT AS
PREIMPLEMENTATION AND WE MOVE
INTO ACTIVE IMPLEMENTATION WHERE
YOU ARE ACTUALLY HIRING AND
GETTING FIDELITY MONITORING SET
UP AND ACTUALLY DOG YOUR THING
AND WE ARE OBVIOUSLY MOVING
TOWARDS SUSTAINMENT AND WITHIN
EACH OF THE DIFFERENT STAGES, IT
IS NOT ADVANCING AGAIN. I'M
SORRY.
WITHIN EACH OF THE DIFFERENT
STAGES, THEY ARE POPULATED WITH
DIFFERENT IMPLEMENTATION
ACTIVITIES OR IMPLEMENTATION
STRATEGIES AND THINGS THAT FOLKS
OFTEN TIMES THINK ABOUT WHEN
THEY ARE THINKING ABOUT
IMPLEMENTING.
IF YOU LOOK IN THAT GOLD REGION
THERE, THAT IS WHAT FOLKS ARE
NORMALLY TALKING ABOUT, GETTING
THEIR STAFF TRAINED AND SERVING
YOUR PATIENTS AND GETTING
FIDELITY MONITORING IN PLACE.
WHAT IS OFTEN TIMES IGNORED ARE
PREIMPLEMENTATION PARTS OF THAT
PROCESS THAT WE HAVE FOUND IN
OUR WORK TO BE EXTREMELY
IMPORTANT.
ALSO, EXTREMELY COSTLY. THERE
ARE COSTS ASSOCIATED WITH THIS.
SO STRATEGIES, WE KNOW THEY ARE
ESSENTIAL TO IMPLEMENT
INNOVATION WITH SUCCESS AND HAVE
DONE LOTS OF WORK TO SHOW ALL
THOSE TYPES OF IMPLEMENTATION
STRATEGY ARE IMPORTANT AND 46 OF
THEM ARE ESSENTIAL FOR
IMPLEMENTING AN EVIDENCE-BASED
PRACTICE AND WORK OF OURS ABLE
TO PULL OUT 296 SITES ONLY THOSE
THAT ARE CONFIDENT AND ACHIEVE
ACTUALLY THAT POINT OF
SUSTAINMENT. IT TAKES WE CAN
SEE IT TAKES ABOUT 10.5 MONTHS
TO BE ABLE TO COMPLETE YOUR
PREIMPLEMENTATION PROCESS ABOUT
8 TA ENMONTHS TO BE ABLE TO
COMPLETE YOUR -- YOUR
IMPLEMENTATION, ACT OF
IMPLEMENTATION DURATION BEFORE
YOU ACHIEVE COMPETENCY AND 2.5
YEARS OF IMPLEMENTATION PROCESS
AND THINKING ABOUT THAT FROM A
SDIGS MAKER STANDPOINT IF THEY
SAY I WILL BUY THIS ONE
PARTICULAR INTERVENTION BUT WE
ARE NOT TELLING THEM THERE IS AN
ADDITIONAL 2.5 YEARS WORTH OF
WORK FOR THEM AND THEIR AGENCY
AND THEIR ADMINISTRATORS AND
PROVIDERS TO GO THROUGH, THAT IS
WHEN SDIGS MAKERS SOMETIMES FEEL
A LITTLE DUPED BY THE
EVIDENCE-BASED PRACTICE AND FEEL
IT IS MORE EXPENSIVE THAN WHAT
THEY WERE TOLD AND IS IMPORTANT
FOR US DEVELOPING INTERVENTIONS
TO BE VERY CLEAR ABOUT NOT JUST
INTERVENTION COSTS BUT
IMPLEMENTATION COSTS.
I'M SORRY IT KEEPS GETTING
STUCK.
THIS MAPS DIRECTLY ON TO THE
SIC. THAT MEANS AS YOU MOVE
THROUGH EACH OF THE STRATEGIES
YOU WORK THROUGH AS YOU
IMPLEMENT WHATEVER YOUR PROGRAM
IS WE WANT TO ASSESS WHAT ARE
DIRECT COSTS AND INDIRECT COSTS
GOING ALONG WITH IMPLEMENTING
THAT AND WE SOMETIMES HAVE
ACTUAL RECEIPTS.
WE ARE ALSO LOOKING REALLY AT
WHO ARE ACTORS INVOLVED IN THAT
PROCESS AND WHAT IS AMOUNT OF
EFFORT IT TAKES FOR THEM TO DO
THAT PROCESS.
THINKING OF CREATING COST
ANALYSIS, IT IS IMPORTANT TO
KNOW WHO IS COST AND WHO IS
BENEFIT AND THIS IS SOMETHING
THAT THE PAYER WILL BENEFIT FROM
AND PROVIDER IS PUTTING OUT ALL
OF THE COSTS IS WHEN WE HAVE A
LITTLE BIT OF A MISMATCH AND FOR
TYPE OF WORK WE ARE DOING WITH
IMPLEMENTATION WE WANT TO
CONSIDER ALL THESE DIFFERENT
PERSPECTIVES.
WORK WITH COINS IS A EXAMPLE
TABLE WHAT COMES OUT OF COINS
THAT IS NOT ROCKET SCIENCE AND
WHAT IT DOES IS ALLOWS US TO BE
ABLE TO LOOK AT WHO ARE ACTORS
INVOLVED IN IMPLEMENTATION
PROCESS WHERE IN PROCESS ACTORS
ARE ACTIVATED AND WHAT ARE COSTS
ASSOCIATED WITH THAT. IMAGINE
IF A SDIGS MAKER AND
EVIDENCE-BASED PRACTICE PART OF
THE SOLUTION YOU FEEL IT IS
EXPENSIVE AND IF YOU KNOW
STAGING OF EXPENSES AND STAGING
OF THE EFFORT AND ALLOWS YOU TO
MAKE A MORE INFORMED DECISION
ABOUT WHETHER OR NOT THIS IS
SOMETHING THAT THE ENTIRE
PACKAGE IS TOO MUCH OF STICKER
SHO
SHOCK.
WE CAN GET MONEY FOR THAT NOW
AND ACHIEVE GREATER MONEY IN THE
FUTURE AND NOW MAKES SOMETHING
THAT PREVIOUSLY FELL OUT OF
REACH WITHIN REACH FOR US TO
BRING INTO OUR COMMUNITIES.
WE CAN DO IT AT GLOBAL LEVELS OR
AN EXAMPLE FROM MY HEAL TRIAL
LOOKING AT INDIVIDUAL CLINIC
SORT OF I WON'T 2 INTO THE TRIAL
BUT AT THE CLINIC LEVEL WHAT WE
SEE HERE IS USING COINS TOOL WE
ARE ABLE TO SEE IN TERMS OF
EXPERT CONSULTATION THAT IS NEED
TODAY START UP TWO DIFFERENT
CLINICS IS THE SAME AND SIGNING
AGREEMENT COSTS AND READINESS
COSTS IS ABOUT THE SAME AND WHAT
IS DIFFERENT ABOUT THESE TWO
CLINICS IS AMOUNT OF STAFF HOURS
THEY PUT INTO IMPLEMENTATION
PROCESS AND THIS IS
PREIMPLEMENTATION PROCESS AND WE
SEE A $22,000 DIFFERENCE BETWEEN
THEM AND NOT SMALL
COMMUNITY-BASED ORGANIZATIONS
SEEING CLINIC PUTTING EFFORT AND
TIME IN UP FRONT STARTED TO
SERVE CLIENTS MORE QUICKLY AND
LONG STORY SHORT THIS CLINIC
ENDS UP RECOUPING COSTS MORE
QUICKLY.
HERE IS A EXAMPLE WHERE WE USED
COINS AND WE WERE ABLE TO
ACTUALLY SAY WHAT IS MORE
IMPORTANT IMPLEMENTING A
PARTICULAR INTERVENTION AND WAS
WORK WE DID WITH TFCO AND WITH
THIS WE WERE ABLE TO SAY
OPERATIONALIZE THIS SO THAT IN
THE FUTURE THERE IS TWO
DIFFERENT BLENDED IMPLEMENTATION
STRATEGIES YOU HAVE A BUNCH OF
STRATEGIES BUNDLED TOGETHER INTO
ONE AND ONE STRATEGY COSTS MORE
IN TERMS OF HOURS AND ANOTHER
STRATEGY COSTS MORE IN TERMS OF
DOLLARS AND DECISION MAKER COULD
BE ABLE TO THEN SAY WHAT IS IT
WE WANT INTERVENTION BUT DON'T
HAVE HOURS OR WANT INTERVENTION
BUT DON'T HAVE DOLLARS AND IS
DECISION TO MAKE INFORMED
STRATEGY THAT IS BEST TO BRING
EVIDENCE BASED PRACTICE BACK
INTO YOUR ORGANIZATION. ANOTHER
EXAMPLE HOW COINS HAS BEEN USED
LOOKING AT DIFFERENCE AND COSTS
ACROSS DIFFERENT STAGES FOR A
PROGRAM THAT ENDS UP BEING
COMPETENT AND THOSE ENDING UP
DELIVERING SERVICES WELL TO
PATIENTS VERSUS THOSE THAT ARE
NOT CONFIDENT AND THOSE THAT
DISCONTINUE ALL TOGETHER. THIS
IS ANOTHER WAY WE ARE ABLE TO
SEE HOW COSTS SORT OF ARE USED
ACROSS DIFFERENT PHASES TO
INFORM DECISION MAKERS AND I
WANT TO REALLY JUST SAY THAT I'M
HOPING WHAT I HAVE SHOWN IS THAT
WE DON'T JUST WANT TO CONSIDER
INTERVENTION COSTS WHEN THINKING
ABOUT IMPLEMENTING NEW PROGRAMS.
WE AS DEVELOPERS IT IS IMPORTANT
FOR US FROM THE VERY BEGINNING
AND FROM GET-GO AS WE DESIGN
THESE INTERVENTIONS FOR US TO BE
ABLE TO KNOW WHAT ARE THE COSTS
ALSO OF IMPLEMENTING THOSE
INTERVENTIONS.
SO IN CONCLUSION, IMPLEMENTATION
COSTS ARE REAL AND CAN HAVE A
VERY SIGNIFICANT DIFFERENCE ON
OVERALL SUCCESS OF AN
IMPLEMENTATION AND THEY ARE
NECESSARY AND FIGURE NORRED THAT
CAN LEAD TO MISTRUST BY DECISION
MAKERS AND QUEEN'S TOOL CAN
CAPTURE COST TO BE USED BY COST
ANALYSIS THAT THE COIN'S TOOL
ITSELF IS NOT A COST ANALYSIS
TOOL.
THANKS VERY MUCH AND APPRECIATE
YOUR TIME LISTENING.
>> >> THANK YOU. STARTING WITH
A FEW COMMENTS, DAVID YOUR
PRESENTATION WAS WONDERFUL AND
BACK TO A QUESTION FOR YOU ABOUT
MEDICAID ASPECT OF IT AND FOCUS
ON MEDICAID AND FOCUS ON USING
MEDICAID BILLING IS A CRITICAL
PIECE YOU HIGHLIGHTED AND TODD
BROUGHT IN FIVE PERSPECTIVES AND
ASKING A SPECIFIC QUESTION IN A
SECOND BUT THOSE FIVE
PERSPECTIVES MIGHT OR MIGHT NOT
ALIGN WITH EACH OTHER AND HAVE
TO FIGURE OUT HOW TO BRING INTO
ALIGNMENT AND FREYA TALKED ABOUT
TOOLS THAT NEED TO BE BUILT AND
HOW DO YOU ADAPT IT AND MAKE IT
EASY TO USE COMING TO LISA'S
DECISION ON INTERVENTION COSTS
AND ALSO TO THINK THROUGH ALL OF
THE DIFFERENT ASPECTS OF
IMPLEMENTATION COSTS.
A COUPLE OF GENERAL COMMENTS IS
I THINK THAT THE WHOLE
DISCUSSION IS NOT JUST ECONOMIC
EVALUATION OF INDIVIDUAL OR
MULTICOMPONENT INTERVENTION.
ALSO, TO FIGURE OUT HOW YOU
TRANSLATE IS INTO THE REAL WORLD
AND WHAT ARE BARRIERS AND HOW
YOU MAKE IT HAPPEN SERVING AS A
SYSTEM AND BOORS OF VALUE-BASED
ENTITIES TWO INTERESTING
ELEMENTS WE HAVE NOT TALKED
ABOUT AND ONE IS MOSTLY IMPACT
YOU WOULD SEE ON COST SAVING OR
LONGER TERM TREATING MENTAL
HEALTH OR OPIOID USE OR ALCOHOL
USE DISORDERS THAT IS MORE ON
MEDICAL COSTS AND SOCIAL COSTS
AND WHEN YOU ACTUALLY FIGURE OUT
INTERVENTIONS, BECAUSE THE
SECOND PART INCLUDES SOCIAL AND
FINANCIAL INTERVENTIONS YOU SEE
A DIFFERENT GAME.
HAVING BEEN INVOLVED IN PROGRAMS
TAKING ON ENTIRE COST OF CARE
AND HAVING ABILITY TO INCLUDE
SOCIAL ELEMENTS OF CARE SUCH AS
HOUSING, FOOD, MEDICATIONS, ET
CETERA, THERE IS SOMETHING TO
CONSIDER AS I MENTIONED AND NIDA
THINKING THROUGH HOW TO PLAY A
ROLE IN INFLUENCING CMS
[INDISCERNIBLE]. I WILL START
WITH QUESTIONS.
QUESTION DAIID -- AND ABOUT FIVE
PERSPECTIVES THAW DISCUSSED AND
HOW DO YOU TRY TO TAKE A LOOK AT
WHEN PERSPECTIVES DO NOT ALIGN?
LET ME START WITH THAT. ERIC
AND I WILL ASK QUESTIONS AS THEY
COME THROUGH FROM THE AUDIENCE.
>> TODD, WANT ME TO GO FIRST?
>> YES, PLEASE.
>> SOUNDS GREAT. GREAT
QUESTION. IT WASN'T TRIVIAL TO
WORK WITH MEDICAID AND TRY TO
FIGURE OUT HOW TO OPTIMIZE
BILLING CODES.
IT WOULD HAVE BEEN EASY IF WE
DIDN'T WANT TO REALLY DO THE
BEST THAT WE CAN TO OPTIMIZE
WHAT POSSIBLY PEOPLE COULD
RECEIVE. WE WANTED TO REALLY BE
COMPREHENSIVE ABOUT THAT.
NOT ONLY E SSSENTIAL LS AND WHA
WE WERE MISSING AND TOOK TIME
AND MASS HEALTH MEDICAID
AUTHORITY HUNG IN THERE WITH US
AND GAVE US LOTS OF TIME AND MY
ADVICE WOULD REALLY BE TO GO AND
SIT WITH YOUR MEDICAID AUTHORITY
AND GO THROUGH WHAT YOU ARE
DOING AND BACK INTO BILLING
CODES.
IF IT IS RELATED TO MISSION,
EASIEST WAY IS TO BRING BILLING
CODES OVER TO YOUR MEDICAID
AUTHORITY THAT THERE ARE BILLING
CODES THAT COULD BE POTENTIALLY
SOMEWHAT UNIVERSAL AND THERE
WOULD BE VARIATION AND HAVE THEM
WORK THROUGH THOSE CODES.
>> TODD TURNING IT TO YOU.
>> QUESTION AND ALIGNMENT OF
PERSPECTIVES TO SOLVE THAT ONE
AND WAY WE LOOK AT IT IS AS A
PRACTICAL MATTER.
PERHAPS MOST IMPORTANT
COMPARISON ACROSS STUDIES OF
DIFFERENT INTERVENTIONS AND
EVERYBODY ADOPTS A SIMILAR
PERSPECTIVE AND IS HELPFUL IN
TERMS OF COMPARING RELATIVE
PROCESS OF DIFFERENT TREATMENTS.
THAT SAID AS A PRACTICAL MATTER
IT IS IMPORTANT PATIENTS GOOD
DEAL FOR PATIENTS AND CLINIC AND
PAYERS WHOEVER THEY ARE.
THAT IS A BARRIER TO
IMPLEMENTATION THIS STAGE OF THE
GAME WE ARE TRYING TO SEE WHAT
POTENTIAL BARRIERS AND
PERSPECTIVE WILL BE
[INDISCERNIBLE] AND ONE MORE
THING ON THAT. MORE GENERALLY
IS A NOTION OF A [INDISCERNIBLE]
POC
POK PROBLEM AND WRONG POCKET
PROBLEM IS WHEN IMPLEMENTATION
COSTS DISPROPORTIONATELY BY BUN
ENTITY IS ENJOYED BY ANOTHER
ENTITY AND WHEN IT HAPPENS WE
HAVE LIKELIHOOD AND PROBLEM WILL
BE CHRONICALLY UNDERFUNDED THAT
HAPPENS ALL THE TIME PROGRAMS AT
INTERSECTION OF MEDICAL
SOCIALIZATIONS AND NO GREAT
SOLUTION FOR WRONG POCKET
PROBLEM I'M AWARE OF PUT OUT A
PROPOSAL A FEW YEARS AGO FOR
FOLKS TO EXAMINE THIS AND MAYBE
SOMEONE ON THE CALL OR PANELISTS
MIGHT KNOW WHAT THAT IS AND THAT
WOULD BE WONDERFUL IF WE COULD
MAKE THAT HAPPEN. THANK YOU.
>> WANT TO ASK THE NEXT
QUESTION?
DR. NEZIR, WE HAVE A QUESTION
FOR YOU ASKING HOW YOU ALIGN
INTEREST OF PAYERS PROVIDERS AND
PATIENTS IN THE LONG TERM.
TYPICALLY WE PRESENT IN
LITERATURE AND COST
EFFECTIVENESS ANALYSIS OF
ECONOMIC EVALUATION.
IT SEEMS IN REAL WORLD RETURN ON
INVESTMENT AND DECISION MAKERS
CARE MORE ABOUT RETURN ON
INVESTMENT AND MY
[INDISCERNIBLE] WHEN WE HAVE
CLEAR EVIDENCE ON SHARED RETURN
ON INVESTMENT PAYERS CARE ABOUT
REDUCED LONG TERM UTILIZATION
AMONG OTHER THINGS MAINLY AND
FOR PROVIDERS IT IS MORE
RELIABLE FUNDING AND PA PATIENT
WANT ACCESS RECOVERY OUTCOMES
AND ALIGNING THESE MIGHT BE LIKE
PAYMENT MODELS REFLECTING
TIME-BASED RETURN AS WELL AND UP
FRONT INVESTMENT THAT IS
PROVIDERS BEING MORE VOVED IN
THAT PHASE AND MIDTERM BREAK
EVEN FOR PROVIDERS AND PAYERS
AND LONG TERM SAVINGS FOR PAYERS
AND TOOLS LIKE THIS BREAK EVEN
CALCULATORS OR MULTIPAY ER RETUN
ON INVESTMENT MODELS THAT NEED
TO BE [INDISCERNIBLE]
TRANSPARENTLY SHARING WHAT COSTS
AND BENEFITS CAN BE IN EACH LYE
TIME OF A PROGRAM WHAT WE WOULD
EXPECT AND LATER ON COULD BE
NEGOTIATION POINTS BETWEEN
DIFFERENT DECISION MAKERS AND
AGAIN IS A VERY YOU KNOW
DIFFICULT QUESTION THAT IS A
START TO THINKING ABOUT WHO IS
INTERESTED AND MOSTLY AT
OUTFRONT OF DECISION OF
DIFFERENT PHASES AND INTRODUCING
A PROGRAM AND WHAT ARE PROVIDERS
NEEDING AND HOW CAN WE LET'S
LOOK AT PAYMENT MODELS TO
ADDRESS THEM VERSUS IN LONG TERM
PAYERS MIGHT BE MORE INTERESTED
AND RETURN ON INVESTMENT AND
SHARED RETURN ON INVESTMENT
MODELS MIGHT BE A WAY TO START
TO LOOK INTO THAT.
WE DON'T HAVE IT.
I MEAN, WHICH WE -- ECONOMIC
LITERATURE, NOT MUCH, I WOULD
SAY.
WE HAVE SOCIETAL PERSPECTIVE WE
USE IN COST EFFECTIVENESS
ANALYSIS THAT I THINK AS I TRIED
TO DESCRIBE IN THE PRESENTATION
REAL WORLD DECISIONS THAT WE
STILL ARE TOO DEVELOPMENTS TO
LOOK INTO.
>> I THINK YOU BROUGHT UP A
CRITICAL POINT AND DECISION
MAKER HAVING TO MAKE CHOICES
TOOLS DON'T EXIST AND YOU HAVE
TO OFTEN WORK OUT BASED ON LOCAL
CONTEXT AND KEEP ADAPTING AND
THINK THAT YOU ARE BRINGING UP A
CRITICAL POINT THAT WE HAVE TO
FIGURE OUT HOW TO CREATE THESE
TOOLS THAT I THINK ALSO CONNECTS
TO THE TYPE OF STRATEGY THAT WAS
-- TODD WAS CONDUCTING.
YOU NEED DATA TO RUN THE TOOLS
SO YOU CAN PROPERLY MAKE
DECISIONS AND THINK THAT BOTH OF
YOU HAVE BROUGHT UP CRITICAL
POINTS.
IF YOU WANT TO ASK THE NEXT
QUESTION, ERIKA, OR --
>> SURE. GREAT POINTS ALL
AROUND. I WOULDN'T MENTION YOU
KNOW THESE PRESENTATIONS
HIGHLIGHTED SEVERAL ECONOMIC
TOOLS TO USE DURING DIFFERENT
PHASES OF IMPLEMENTATION
PLANNING AND SUSTAINMENT AND
SCALE-UP AND WONDERING IF
PANELISTS CAN COLLECTIVELY SPEAK
TO HOW YOU WORK WITH LOCAL
DECISION MAKERS AND MORE NITTY
GRITTY DETAILS TO THINK ABOUT
HOW TO SELECT THE RIGHT TOOL OR
ECONOMIC EVALUATION APPROACH FOR
LOCAL CONTEXT OR END GOAL NEEDS
AND IF YOU WANT TO TALK ABOUT
HOW THAT APPROACH DIFFERS AND IF
YOU ARE WORKING WITH
ORGANIZATIONS AND HEALTH SYSTEM
DECISION MAKERS AND STATE AGENCY
DECISION MAKERS WE WELCOME THAT
DETAIL AS WELL.
>> I WOULD LIKE TO CHIME IN WITH
THAT.
MY WHOLE PRESENTATION I THINK
WAS ABOUT THAT.
TOOLS I MENTIONED ARE NOT THERE.
THEY ARE NOT THERE FOR US
RESEARCHERS TO USE AND WERE
SUGGESTIONS TO BUILD THESE
TOOLS. THEY SEEM TO BE MORE
RELEVANT FOR DECISION MAKERS.
WE DON'T HAVE THE TWO AS FAR AS
I KNOW TO PICK FROM AND GENERAL
APPROACH IS COST EFFECTIVENESS
ANALYSIS FOR MOSTLY I MEAN
PUBLICATION PURPOSES.
IT IS LIKE DATA BUT NOT LOCALLY
TRANSFERABLE AND LOCALLY USABLE
FOR DECISION MAKING AND THOSE
TOOLS WE ARE TO DEVELOP, I
THINK.
I THINK THAT PRETTY MUCH IS
IMPORTANT AND WE DON'T HAVE THAT
INFRASTRUCTURE AND CALL TO
ACTION WAS LET'S WORK ON
BUILDING THIS INFRASTRUCTURE AND
COST EFFECTIVENESS NORMAL
ECONOMIC EVALUATION WE HAVE
DOESN'T SEEM TO FIT TO SO-CALLED
REAL WORLD DECISIONS.
>> ERIKA, IF YOU DON'T MIND, IF
I CAN JUMP IN FOLLOWING FREYA
THERE. I THI THINK THAT IS RIG
AND HOPE TO HINT A LITTLE OF
THAT IN MY PRESENTATION AND
BELIEVE WAY WE PRESENT
INFORMATION AND INFORMATION THAT
IS USEFUL TO DIFFERENT
CONSTITUENTS ARE QUITE
DIFFERENT.
SO JUST LIKE FREYA WAS SAYING,
WHEN I'M GOING AND MEETING AN
INDIVIDUAL ORGANIZATIONAL LEADER
OR EXECUTIVE DIRECTOR, THEY ARE
NOT INTERESTED IN THE OVERALL
COST EFFECTIVENESS WE MIGHT
MENTION THAT AND WHAT CATCHES
OUR ATTENTION AND WHAT STARTS
THE CONVERSATION AND IN TERMS OF
ACTUALLY DECIDING WHETHER OR NOT
THEY ARE GOING TO IMPLEMENT
SOMETHING, THEY ARE REALLY
INTERESTED IN WHAT IS SORT OF
THE BEAR BONES NEEDS TO LIKE
WHAT ARE THE STRATEGIES THAT
WILL BE NEEDED TO IMPLEMENT THIS
PROGRAM TO BE ABLE TO IMPLEMENT
IT WITH FIDELITY AND THINK THAT
IS WHERE I HAVE A LOT OF
CONVERSATIONS SOMETIMES FOLKS
ARE ASKING IF THERE ARE PARTS OF
THE INTERVENTION THEY MIGHT BE
ABLE TO CUT CORNERS ON OR
DECREASE AMOUNT OF TIME THEY
HAVE FACILITATION MAYBE OR
COACHING IN A PARTICULAR MODEL.
ONE THING I OFTEN TIMES AM
TALKING TO THEM ABOUT IS YES WE
CAN DO THOSE COST CUTTING
MEASURES UP FRONT. THAT IS THEN
GOING TO PRODUCE A PROGRAM LESS
LIKELY TO SUSTAIN INTO THE
FUTURE AND AT THAT POINT THOSE
ARE LOST COSTS; RIGHT?
WE START TO HAVE CONVERSATIONS
WHAT IT TAKES SORT OF IN THAT
BASIC WAY AND WHAT WE CAN DO NOW
AND PLAN FOR THAT ALONG THAT
PINNUM OF THE IMPLEMENTATION
PROCESS FOR THEM TO BE ABLE TO
DELIVER SOMETHING WITH FIDELITY
AND WHAT WE ARE ABLE TO SHOW
WITH COINS IS WE CAN SHOW THEM
HOW LONG IT TAKES FOR THEM TO
START TO BE ABLE TO RECOUP UP
FRONT AND WHAT OFTEN TIMES
PEOPLE REFER TO AS SUNK COST AND
DON'T LIKE TO REFER TO THEM AS
SUNK KOCHTS THAT ARE VERY REAL
COSTS TO THE AGENCY LAND OR NOT
THEY ARE COSTS IN THE FUTURE, IT
DOESN'T MATTER.
IN THAT MOMENT, IT WILL
DETERMINE WHETHER OR NOT THEY
CAN MAKE IT IN THEIR BUDGET AND
HOW I THINK ABOUT COINS SORT OF.
YES. IT CAN BE USED TO INFORM
ECONOMIC ANALYSIS.
IT CAN ALSO BE USED IN EVERY-DAY
DISCUSSIONS WITH DECISIONMAKERS.
>> I THINK THAT THIS APPROACH IS
REALLY INTERESTING.
IT COULD BE VERY VALUABLE IN
MANY INSTANCES.
THANK YOU FOR TALKING ABOUT IT.
I HAVE ONE QUESTION COX K FROM
AUDIENCE WORKING IN RURAL AREA
MIGHT NOT HAVE RESOURCES TO
PROVIDE THOSE. ANY SUGGESTIONS
FROM ANY PANEL MEMBERS HOW TO GO
ABOUT IT?
IT WAS RAISED IN CONTEXT OF
COLLABORATIVE CARE THAT I THINK
IS APPLICABLE TO EVERYTHING
RAISED WHEN YOU DON'T HAVE THE
RIGHT KIND OF PEOPLE AND IS
PROBABLY TRUE FOR A GOOD PART OF
THE COUNTRY.
WHAT DO YOU DO?
>> PSYCHIATRY SEEMS TO BE ONE
WAY TO GO.
SHARED CARE MANAGERS ASICROSS
SITES.
>> YEAH. I WOULD ADD THIS IS
DAVID.
FOR MISSION, WE STARTED TO TEST
TELEHEALTH MODEL AND THEN IN THE
DEPARTMENT OF VETERAN AFFAIRS
AND NOW HAVE A VIRTUAL CARE HUB
THAT IS OPERATING IN A NUMBER OF
DIFFERENT RURAL AREAS THAT SEEMS
OWE BE WORKING REASONABLY WELL
AND REAL QUESTION FOR US, YOU
KNOW, WHAT POPULATIONS IS IT
REASONABLE ENOUGH?
AND YOU KNOW WHEN DO YOU NEED
IN-PERSON CARE AND HOW TO DO
THAT?
WE ARE STARTING TO LOOK AT IT
NOW.
>> I WOULD ALSO SAY MY TEAM AND
I HAD THE GREAT PRIVILEGE BEING
ABLE TO WORK WITH A NUMBER OF
DIFFERENT COLLABORATIVE CARE
GROUPS.
SO DIFFERENT PLACES AROUND THE
COUNTRY AND DIFFERENT CONTEXTS
AND PARTICULAR POPULATIONS THAT
THEY MIGHT BE WORKING WITH AND
WHAT WE FOUND IN ECONOMIC
ANALYSIS IS THAT IF YOU CAN
DEVELOP A COHORT MODEL OF
IMPLEMENTATION WHERE YOU ARE
IMPLEMENTING WITH A REAL SET OF
DIFFERENT COLLABORATIVE CARE
TEAMS AT THE SAME TIME THAT CAN
REALLY HELP TO REDUCE COSTS.
SO THAT REALLY CUTS DOWN ON
TRAINING COSTS MAKING THEN
COLLABORATIVE CARE MORE OPEN OR
MORE AVAILABLE TO A GREATER PART
OF THE POPULATION.
IT IS NOT THAT THE MODEL ITSELF
CHANGES BUT MODEL ITSELF STILL
HAS FIXED COSTS OF THE THING AND
HOW WE IMPLEMENT IT IS -- CAN
MAKE AN IMPACT ON NUMBER OF
FOLKS THAT WE ARE ABLE TO REACH
WITH THAT MODEL.
>> THANK YOU, ERIC.
WANT TO ASK THE LAST QUESTION?
WE ARE RUNNING OUT OF TIME AND
VERY GOOD DISCUSSION SO FAR.
>> YEAH. GREAT DISCUSSION.
EARLY THANK YOU TO OUR
PANELISTS.
LAST AUDIENCE QUESTION WE HAVE
IS WONDERING ABOUT DIFFERENT
BENEFITS TO THINKING ABOUT
IMPLEMENTATION COSTS BY
DIFFERENT PHASES OF
IMPLEMENTATION VERSUS THINKING
ABOUT IMPLEMENTATION COSTS
ACROSS ALL PHASES TOGETHER.
>> YEAH. THANK YOU. I WILL
TAKE THAT. THAT IS PRETTY MUCH
ON PAR WITH WHAT WE HAVE BEEN
TALKING ABOUT THUS FAR AND JUST
IN TERMS OF BEING ABLE AND FACT
THAT WE ARE ABLE TO SAY THIS IS
WHAT IT LOOKS LIKE IN
PREIMPLEMENTATION AND WHAT
AVERAGE COSTS ARE FOR PARTICULAR
INTERVENTION AND EVIDENCE-BASED
PRACTICE ARE AVERAGE COST FOR
ACTIVE IMPLEMENTATION STAGE AND
IF YOU RECALL IN MY PRESENTATION
THAT THOSE PHASES ARE QUITE LONG
TO BE ABLE TO ACCOMPLISH.
WITH SIC PART OF COINS PROCESS
WE CAN BREAK IT DOWN FURTHER
INTO STAGES.
AS I MENTIONED, ONE THING THAT
IS REALLY IMPORTANT IS THE WHO
THAT IS AVAILABLE NEEDING TO
ACTIVATE STAGES AND IS ANOTHER
WAY WE CAN REALLY THINK ABOUT
COSTS IS IF WE ARE ABLE TO
DEPLOY A LESS EXPENSIVE
WORKFORCE WITHIN ORGANIZATIONS
TO HELP WITH IMPLEMENTATION AND
MIGHT BE APPROPRIATE AT ONE
PHASE OF THE IMPLEMENTATION
PROCESS UNLESS INAPPROPRIATE AT
ANOTHER PHASE AND THINK A NICE
THING AND REALIZE I'M BIAS AND
ANOTHER THING TO BASIC APPROACH
IS IT ALLOWS US TO PLAN AND
FORECAST AND BE REALLY
DELIBERATE WITH USE OF DOLLARS
IN THAT IMPLEMENTATION PROCESS.
>> THANK YOU. I THINK WE HAVE
RUN OUT OF TIME AND WE WANT TO
THANK ERIKA AND DAVID AND FREYA
AND LISA FOR A VERY GOOD
DISCUSSION AND CLEAR
PRESENTATION.
THANK YOU ALL.
>> YES. THANK YOU ALL AND TO
ERIKA AND RANGA FOR RUNNING THE
DISCUSSION.
WE HAVE LEARNED WHAT WE ARE
ADAPTING TO THE NEW TEAMS
ENVIRONMENT THAT SOME OF US
PARTICULARLY ON NIH SIDE ARE
HAVING DIFFICULTY ACCESSING THE
Q & A AND WILL LEAVE IT UP HERE
FOR A MINUTE IF YOU WANT TO
WRITE DOWN THE E-MAIL ADDRESS
AND SEND QUESTIONS TO CLAIRE,
OUR CONTRACTOR.
WE -- FOR ANYONE FOLLOWING ALONG
THROUGH NIH TELECAST THIS IS THE
E-MAIL ADDRESS PROVIDED THROUGH
NIH VIDEO CAST FOR SUBMITTING
QUESTIONS AND IF YOU HAVE
FUNCTIONALITIES IN THE Q & A USE
THAT. WITH THAT TURNING IT TO
MARY FROM MENTAL HEALTH AMERICA
COORDINATING OUR DISCUSSION ON
FINANCING AND PAYMENT MODELS.
>> GOOD MORNING, EVERYONE. I'M
ECSTATIC TO BE HERE TODAY. I'M
PASSIONATE ABOUT PAYMENT POLICY
BECAUSE AS YOU WILL SEE FROM
THESE PRESENTATIONS IT MAKES A
DIFFERENCE IN ABILITY OF PEOPLE
WITH MENTAL HEALTH AND SUBSTANCE
USE CONDITIONS TO ACCESS OFTEN
LIFE-SAVING CARE.
YOU WILL HEAR ABOUT A VARIETY OF
PAYMENT MODELS WHETHER
FEE-FOR-SERVICE OR BUNDLED
PACKAGES OR VALUE-BASED PAMENT.
IN ADDITION YOU WILL HEAR ABOUT
SIGNIFICANT FACTORS THAT CAN
EFFECT OUTCOMES AND THINGS LIKE
HOW SEVERE IS THE ILLNESS AND IS
IT SERIOUS MENTAL ILLNESS FOR
EXAMPLE WHERE DOES THE PERSON
LIVE AND HOW DO RURAL PARTS GET
ACCESS TO CARE AND END OF LIFE
PERINATAL CARE IS IMPORTANT TO
WOMEN AND TO CHILDREN; RIGHT?
THROUGH THIS ALL THINK THAT THE
MESSAGE I CAME FROM IN TALKING
TO PRESENTERS THAT I KNOW I HOPE
YOU WILL TOO IS WE HAVE SO MUCH
TO LEARN. OF COURSE, THE BEST
WAY TO LEARN THAT IS THERE YOU
RESEARCH AND WE NEED TO REALLY
LEARN MORE TO UNDERSTAND HOW DO
WE FINANCIALLY INCENTIVIZE WHAT
WE WANT TO SEE WHICH IS STRONG
HEALTH OUTCOMES IN MENTAL HEALTH
AND SUBSTANCE USE AREA NOT JUST
AVOIDING BAD OUTCOMES LIKE
EMERGENCY USE OR EMERGENCY ROOM
USE OR HOSPITALIZATIONS BUT ALSO
POSITIVE THINGS; RIGHT?
HOW WILL WE FINANCIALLY
INCENTIVIZE WHAT WE WANT TO SEE
AND MAKE IT EASY FOR PEOPLE AND
FOR PROVIDERS?
WITH THAT, I AM REALLY EXCITED
ABOUT PRESENTATIONS THAT WE WILL
DIVE INTO SOME OF THE IMPORTANT
ISSUES.
AS WAS PREVIOUSLY NOTED WE ARE
REALLY INTERESTED IN THE
QUESTIONS AND WILL GET TO THEM
AT THE END.
AND YOU HAVE BEEN ASKED TO
E-MAIL THEM AT CLAIRE
CLAIRE.BARED AT DUKE.EDU.
E-MAIL QUESTIONS THERE AND SEND
THEM TO BE ME AND GET TO THE END
OF THE PRESENTATION AND NOW
LET'S GET STARTED WITH THE FIRST
SPEAKER DR. BETH MCGINTY FROM
WILD CORNELL MEDICINE.
DR. MCBEGINTY.
>> THANK YOU SO MUCH FOR THE
FANTASTIC INTRODUCTION.
EVERYBODY OKAY?
>> YES. YES.
>> AH SMCHLT THANK YOU. I'M
GOING TO KICK OFF THIS SECTION
WITH AN OVERVIEW OF A PROJECT
THAT WE COMPLETED ABOUT A YEAR
AGO.
IT DID A LANDSCAPE ANALYSIS AND
QUALITY OF WORK WITH EXPERTS IN
PAYMENT POLICY TO UNDERSTAND THE
LANDSCAPE AND PERCEIVED
OPPORTUNITIES AROUND PAYMENT
OPTIONS AND HIGH LEVEL OVERVIEW
TO TEE UP COMING EXPERT
PRESENTATIONS NICELY. NEXT
SLI
SLIDE.
THIS IS WHERE I'M HEADED NEXT
AND DISCUSSING PROJECT AND
JUMPING INTO PRIMER AROUND KEY
POLICY PAYMENT CONCEPTS WE WORK
TO CHARACTERIZE IN LANDSCAPE
ANALYSIS AND GIVING A HIGH-LEVEL
OVERVIEW OF MOUD POLICY
LANDSCAPE AS IT CURRENTLY STANDS
WARNING YOU IT IS NOT
STRAIGHTFORWARD AND THERE IS A
LOT OF IT DEPENDS ON A, B, OR C.
I WILL GIVE YOU PROBABLY MORE OF
A SNAPSHOT THAN A COMPREHENSIVE
VIEW AND WILL TEE US UP FOR
IN-DEPTH LOOKS AT SPECIFIC
ISSUES IN REMAINING SECTIONS OF
THIS PANEL.
I'LL SHARE WHAT EXPERTS VIEWED
AS KEY OPPORTUNITIES IN PAYMENT
POLICIES FOR MOUD MEDICATION FOR
OPIOID USE DISORDER AND
HIGHLIGHT THAT WORK HAS BEEN
PUBLISHED IN HEALTH AFFAIRS
SCHOLAR AND IT WOULDN'T HAVE
BEEN POSSIBLE WITHOUT MY
FANTASTIC COLLABORATORS AND
WHITE MATTISE ENBERG AND
BRENDAN. NEXT SLIDE, PLEASE.
MOTIVATION HERE IS UNDERSTANDING
HOW MOUD SERVICES ARE PAID FOR
AND HOW WE MIGHT DO A BETTER JOB
AT DESIGNING PAYMENT POLICY.
IN PRACTICE, THIS IS MOSTLY
ABOUT INSURANCE PAYMENT DESIGN.
THAT IS WHERE WE FOCUSED IN THE
PROJECT AND WHERE I WILL FOCUS
IN THE TALK.
THERE ARE OTHER FUNDING
MECHANISMS LIKE BLOCK GRANTS
THAT ARE RELEVANT. IMPORTANT
CONCEPTS OUTSIDE OF SCOPE FOR
PURPOSES OF OUR TIME HERE
TOGETHER THIS MORNING.
WHY DO WE CARE?
THIS IS PERHAPS OBVIOUS AND
THINK IT IS USEFUL TO MOTIVATE A
BIT.
FIRST OF ALL, ADEQUATE PAYMENT
IS A NECESSARY CONDITION OF
SERVICE DELIVERY AND IF
PROVIDERS ARE NOT PAID ENOUGH
TREATMENT IS NOT DELIVERED.
PAYMENT DESIGN INTRODUCES
INCENTIVES THAT INFLUENCE VOLUME
AND QUALITY OF THE SERVICES
DELIVERED. HOW WE DESIGN
PAYMENT IS A KEY POLICY WEAVER
TO SCALE EFFECTIVE TREATMENTS
LIKE MOUD.
OF COURSE WE HAVE A MAJOR MOUD
TREATMENT GAP WHERE WE KNOW IT
IS A HIGHLY EFFECTIVE TREATMENT
THAT MANY PEOPLE ARE NOT OFFERED
OR WHO HAVE DIFFICULTY ACCESSING
IT EVEN WHEN INTERESTED AND
PAYMENT POLICY IS, ONE,
CERTAINLY NOT ONLY LEVER TO HELP
CLOSE THAT GAP. NEXT SLIDE,
PLE
PLEASE.
BRIEFLY AND IN A NUTSHELL TO
HELP TEE UP LANDSCAPE I WILL
SHOW IN A MINUTE WE HAVE THREE
PREDOMINANT INSURANCE PAYERS IN
THE US AND THREE GROUPS WE
FOCUSED ON IN LANDSCAPE ANALYSIS
AND MEDICARE AND OLDER ADULTS
AND THOSE YOUNGER EXPERIENCING
DISABILITY TRADITIONAL MEDICARE
AND MEDICARE ADVANTAGE AND
MEDICAID AND PROGRAM FOR LOW
INCOME AMERICANS AND AGAIN WE
HAVE TWO FLAVORS FEE-FOR-SERVICE
AND MEDICAID MANAGED CARE AND
THAT LANDSCAPE IS COMPLEX WITH
MANY STATE MEDICAID PROGRAMS
CONTRACTING WITH MULTIPLE MCOS
AND MA N AGED CARE ORGANIZATIONS
THAT THERE ARE OVER 280 MEDICAID
MANAGED CARE ORGANIZATIONS IN
THE US AND IS RELEVANT. THEY
MIGHT EACH HAVE OWN MOUD PAYMENT
POLICIES AND PRIVATE HEALTH
PLANS EMPLOYER SPONSORED PLANS
AND PLANS ON SMALL GROUP AND
INDIVIDUAL MARKET.
NEXT SLIDE. CONTINUING WITH OUR
PRIMER AND HIGH-LEVEL OVERVIEW
OF PAYMENT MODELS THAT WE USE TO
CATEGORIZE OUR FINDINGS IN THE
LANDSCAPE ANALYSIS.
FEE-FOR-SERVICE IN A NUTSHELL
FOR EACH BILLABLE SERVICE AND
CLINICIAN IS PAID A FEE AND
CAPITIATED PAYMENT IS WHEN WE
HAVE A LUMP SUM PAYMENT FROM
INSURER TO PROVIDER OR
ORGANIZATION AND OWE FRN IN A
PER MEMBER PER MONTH TYPE OF
FORMAT AND BUNDLED PAYMENT IS
WHEN INSURER PAYS PROVIDER A
WEEKLY OR MONTHLY FEE FOR
DELIVERING A GROUP OR BUNDLE OF
SERVICES.
AND VALU-BASED PAYMENT IS MODEL
THAT TIES PAYMENT TO PERFORMANCE
AND PAYMENT DESIGNS ABOVE CAN BE
TECHNICALLY VALUE-BASED IF TYING
SOMEHOW THAT PAYMENT DESIGN TO
PERFORMANCE METRICS.
EACH OF THE DESIGNS INTRODUCES
DIFFERENT INCENTIVES AROUND
VOLUME AND KWALET THAT IS A
WHOEP SEPARATE TALK AND AT A
VERY HIGH LEVEL FEE-FOR-SERVICE
ALONE CAN INCENTIVIZE VOLUME
OVER QUALITY.
MORE -- GREATER NUMBER OF
SERVICES YOU PROVIDE, MORE
REIMBURSEMENT YOU GET.
CAPITIATED PAYMENT CAN
INCENTIVIZE SKIMPING ON CARE.
YOU ARE GETTING A LUMP SUM
PAYMENT AND LESS SERVICES THAT
YOU DELIVER, THE MORE MONEY THE
INSURER MAKES.
NEXT SLIDE.
SO OUR FINAL PRIENLER ELEMENTS
HERE, PAYMENT POLICY DESIGN
ELEMENTS THAT WE CHARACTERIZE.
DEDUCTIBLES AND AMOUNT PAID BY
PATIENT INSURANCE COVERAGE
BEFORE IT BEGINS. COPAYMENTS,
SET AMOUNT PAID OUT OF POCKET
FOR SERVICE AND COINSURANCE IS
SIMILAR TO COPAYMENT BUT
PERCENTAGE OF COSTS OF A SERVICE
AND WE ALSO HAVE UTILIZATION
MANAGEMENT STRATEGIES AT PLAY
THAT ARE STRATEGIES THAT
ENSURERS USE LIKE PRIOR
AUTHORIZATION OR STEPPED
TREATMENT OR VISIT LIMITS TO
MANAGE CARE AND IN PRACTICE THAT
MEANS PAYMENT FOR GIVEN SERVICE
LIKE THIS PRESCRIPTION IS
PREDICATED ON USE OF ONE OF THE
STRATEGIES LIKE CLINICIAN MUST
OBTAIN PRIOR AUTHORIZATION FROM
THE INSURER BEFORE PRESCRIBING
AN MOUD.
WE HAVE ALSO GOOD EVIDENCE FROM
THE PRIOR LITERATURE THAT
GENERALLY SPEAKING GREATER COST
SHARING AND UTILIZATION
MANAGEMENT INCREASE -- EXCUSE
ME. DECREASES USE OF THAT KIND
OF TREATMENT.
NEXT SLIDE.
ALL RIGHT. NOW, JUMPING INTO
THE LANDSCAPE AND I TRIED TO
SIMPLIFY WHAT ARE GIANT TABLES
PRODUCED IN LANDSCAPE ANALYSIS
AND SOMETHING DIGESTIBLE IN A
SLIDE FORMAT AND DO JOB TO
WHETHER WE SUCCEEDED AND FIRST
THING WE LOOKED AT IS MOUD
COVERAGE ACROSS DIFFERENT
INSURANCE TYPES THAT WE
EXAMINED.
AND THE HIGH-LEVEL QUESTION WAS
DO EACH OF THE INSURANCE
CATEGORIES COVER AT LEAST ONE
FORMULATION OF ALL OF THE FDA
APPROVED MEDICATIONS FOR OPIOID
USE DISORDER. THE ANSWER IS
YES.
FOR TRADITIONAL MEDICARE AND
MEDICARE ADVANTAGE AND IT IS YES
FOR MEDICAID AND QUALIFICATION
THAT THE FEDERAL LAW AND SUPPORT
ACT THAT REQUIRED STATES TO
OFFER AND COVER AT LEAST ONE
FORMULAITION THAT PROVISION
EXPIRED IN SEPTEMBER OF 2025 AND
PRIVATE INSURANCE VARIES BY PLAN
AND METHO DON'T IN PARTICULAR IS
LEAST LIKELY TO BE COVERED.
NEXT SLIDE.
SO HERE, WE LOOKED AT
REIMBURSEMENT MODEL AND PRIOR
AUTHORIZATION REQUIREMENTS AND
LOOKED AT THINGS I INTRODUCED IN
THE PRIMER AND I'M SHOWING
REIMBURSEMENT MODEL AND PRIOR
REQUIREMENTS ACROSS VARYING
INSURANCE GROUPS THAT IS FOR
OFFICE-BASED MEDICATION FOR
OPIOID USE DISORDER NOT OPIOID
TREATMENT PROGRAM BASED AS
DIFFERENCES IN PAYMENT POLICY IN
THE TWO SETTINGS.
I WON'T TALK YOU THROUGH EVERY
SINGLE BOX ON THE SLIDE HERE.
I WILL HIGHLIGHT A COUPLE OF
RELEVANT THINGS AND AGAIN MAKE
THE POINT IF THERE IS A LOT OF
VARIATION ACROSS PAYERS AND
DEPENDING ON THINGS LIKE THE
FORMULATION OF THE MEDICATION
FOR OPIOID USE DISORDER. RIGHT?
FOR EXAMPLE, I WILL WALK THROUGH
MEDICAID. MEDICAID USES MOST
WILL I UNBUNDLED FEE-FOR-SERVICE
MODEL TO REIMBURSE PROVIDERS FOR
DELIVERING MOUD AND OFFICE-BASED
SCIENCE AND PRESCRIBING
NOREPINEPHRINE FOR EXAMPLE THAT
DIFFERS FOR FEDERALLY QUALIFIED
CENTERS AND RURAL HEALTH CENTERS
USING PROSPECTIVE PAYMENT AND
MEDICAID FEE-FOR-SERVICE AND
MANAGED CARE, THERE ARE SOME
EXCEPTIONS WHERE SOME STATES
MIGHT BE USING WAIVERS TO USE
DIFFERENT VALUE-BASED PAYMENT
MODELS OR CAPITIATED PAYMENT
MODELS AND SOME MEDICAID MANAGED
CARE ORGANIZATIONS MIGHT BE ALSO
USING ALTERNATIVE PAYMENT MODELS
AND MCO SIDE THAT IS NOT TOTALLY
TRANSPARENT AND WHAT OTHERS
PRIOR AUTHORIZATION FOR
NOREPINEPHRINE AND NAL TRECHLONE
AND MEDICAID PROGRAM DESIGN AND
FAE FOR SERVICE NCO AND
FORMULAITION AND EXAMPLE
IMMEDIATE RELEASE NOREPINEPHRINE
AND PRIOR OFFICE REQUIRED BY 37%
FEE-FOR-SERVICE PROGRAMS AND 37%
IN MOST OF RECENT DATA AVAILABLE
WE FOUND IN LANDSCAPE ANALYSIS
THAT I BELIEVE IS FROM 2021 AND
SIMILAR VARIATION FOR NAL
TRECHLONE.
NEXT SLIDE.
FOR OPIOID TREATMENT PROGRAMS,
PAYMENT POLICY FOR MOUD DIFFERS
AND MODELS ARE DIFFERENT AND
RELATIVE TO OFFICE-BASED MOUD.
FOR EXAMPLE, AGAIN, IN MEDICAID
CONTEXT, IT IS POSTALLY
UNBUNDLED FEE-FOR-SERVICE
PAYMENTS AND AGAIN WITH BUNDLED
CAPTATED AND VALUE-BASED
PAYMENTS BEING USED ACROSS
PROGRAMS THROUGH LEVERS AND
MANAGED CARE ORGANIZATION
POLICIES AND MEDICARE ON OTHER
HAND USES A BUNDLED PAYMENT
USING VALUE-BASED PAYMENT AND IS
ENDED WAS USING VALUE-BASED
PAYMENT IN VALUE AND OPIOID USE
DISORDER TREATMENT AND PRIOR
AUTHORIZATION AGAIN IS
FEE-FOR-SERVICE AND MCO AND
FORMULAITION AND BY SPECIFIC
PLAN.
NEXT SLIDE.
ALL RIGHT. TO CONCLUDE HERE, WE
DID INTERVIEWS WITH 21 EXPERTS
IN PAYMENT POLICIES FOR MOUD.
ALSO, FOLLOW UP SURVEYS THAT
BUILT ON INTERVIEWS AND GOAL WAS
TO UNDERSTAND AFTER THE
LAPPEDSCAPE ANALYSIS THAT HAS
ALL OF THE VARIATION THAT WHAT
THEIR PERSPECTIVE WAS ON THE
BEST MOUD PAYMENT POLICY AND
WHERE WE SHOULD HEAD IN THE
FUTURE AND WHAT ARE THE
OPPORTUNITIES AND WHAT I HEARD
IS LACK OF CONSENSUS ON A BEST
MODEL AND A CAUTION AGAINST
RIGID ONE-SIZE FITS ALL
APPROACHES THAT I THINK PERHAPS
HELPS TO EXPLAIN AT LEAST IN
PART A BUNCH OF THE VARIATION
THAT I SHOWED IN THE LANDSCAPE
ANALYSIS.
ONE EXAMPLE OF CAUTION AGAINST
THE ONE-SIZE FITS ALL
APPROACHES, FOR EXAMPLE, WAS
THAT DIFFERENT PAYMENT MODELS
MIGHT BE BETTER FOR LARGE
PRACTICES WITH HIGH VOLUMES OF
PATIENTS WITH OPIOID USE
DISORDER VERSUS SMALL PRACTICES
WITH LOW FOLLOW UP AND VALUE
BASED PAYMENT WAS CONSISTENTLY
RECOGNIZED AS A PRIORITY AND NOT
WIDELY USED AND CONSENSUS AMONG
EXPERTS IS IT WASN'T READY FOR
PRIME TIME FOR TWO MAIN REASONS
TO IMPROVE CAPACITY AND TRACK
AND REPORT DATA AND NEED FOR
VALIDATED PERFORMANCE METRIC.
NEXT SLIDE. SUMMING UP WHAT I
SAID AND I WILL STOP HERE IN
INTEREST OF TIME. THANKS.
>> THANKS, BETH. NEXT SPEAKER
IS DR. MARCELA HORVITZ-LENNON
FROM HEALTH EVALUATION RESEARCH
LAB AND HEALTH ALLIANCE AND
RAND.
>> HELLO, EVERYONE. CAN
EVERYONE HEAR ME WELL?
>> YES.
>> GREAT.
GOOD MORNING AND DELIGHTED TO BE
HERE TO PRESENT NEW IMPACTS ON
MEDICAID VALUE BASED PAYMENT AND
POLICIES YOU HEARD ABOUT AMONG
ADULTS WITH SERIOUS MENTAL
ILLNESS AND ACKNOWLEDGING
SUPPORT FROM RESEARCH FROM NIMH.
AND MULTIPLE COLLABORATORS AND
VARIOUS INSTITUTIONS LISTED
THERE OF WHICH I WILL HIGHLIGHT
NEW YORK STATE DEPARTMENT OF
HEALTH WHO PROVIDED INVALUABLE
INSIGHT AND CREDIBLE DATA FOR
RESEARCH.
NEXT SLIDE, PLEASE.
BEFORE PRESENTING OUR RESEARCH
AND FINDINGS, I WILL BRIEFLY
REVIEW WHAT MOTIVATED OUR
RESEARCH DESCRIBED BRIEFLY WITH
POLICIES IN MEDICAID AND SPEND A
BIT MORE TIME ON THE NEW YORK
STAGE, MEDICAID VALUE-BASED
POLICY. NEXT SLIDE, PLEASE.
SO MEDICAID IS VERY, VERY
IMPORTANT PAYER FOR PEOPLE WITH
VERY SERIOUS MENTAL ILLNESS AND
WE NEED INDIVIDUALS
SCHIZOPHRENIA BIPOLAR DISORDER
AND SERIOUS MAJOR DEPRESSIVE
DISORDER. DESPITE AVAILABILITY
OF EFFECTIVE TREATMENTS AND
EVIDENCE-BASED PRACTICES AND
HIGH COSTS TO MEDICAID PROGRAMS
AROUND THE COUNTRY OUTCOMES FOR
POPULATIONS ARE GENERALLY PRETTY
[INDISCERNIBLE]. AMONG DRIVERS,
KEY ACTIONABLE DRIVERS ARE IN
ADEQUATE ACCESS AND QUALITY OF
MEDICAID FINANCED SERIOUS MENTAL
ILLNESS CARE.
NEXT SLIDE, PLEASE.
VARIETY OF STRATEGIES THAT CAN
BE BROUGHT TO BEAR TO ADDRESS
FOUR OUTCOMES INCLUDE FINANCING
POLICY THAT WE ARE HERE TO TALK
ABOUT.
AND OUR FOCUS FOR THIS RESEARCH
WAS VALUE-BASED PAYMENT, BPP FOR
SHORT AND CORNERSTONE AND
LINKING OF QUALITY AND SPENDING
GOALS AND POLICIES TEND TO
INCLUDE EXPECTATIONS AND
PERFORMANCE STANDARDS INTO
CONTRACTS THAT BUILD THOSE
INTERCONTRACTS AND SHOULD
REQUIRE THAT THE STATE HAS
CAPACITY TO MEASURE AND MONITOR
PERFORMANCE AND IN WILLINGNESS
TO ENFORCE PENALTIES AND
MEDICAID PROGRAMS VARIOUS MODELS
MIGHT BE IDENTIFIED AND ONE OF
WHICH FOCUSES ON HEALTH PLAN
PAYMENTS TO PROVIDERS.
ONE OF THE MODELS IS THAT.
THOSE TEND TO BE GUIDED USING AS
A ROADMAP A FRAMEWORK PUT FORTH
BY THE HEALTH CARE PAYMENT
LEARNING AND ACTION NETWORK.
AN ORGANIZATION THAT HAS CMS
SPONSORSHOP.
DESPITE THE FACT THAT SEVERAL
MEDICAID PROGRAMS HAVE
IMPLEMENTED POLICIES INCLUDING
FOR PEOPLE WITH SERIOUS MENTAL
ILLNESS, LITTLE WAS KNOWN BY THE
TIME THAT WE SUBMITTED OUR GRANT
APPLICATION TO NIMH.
ON IMPACTS AMONG ENROLLEES WITH
SERIOUS MENTAL ILLNESS AND KEY
GAPS INCLUDE NO EVIDENCE ON
ACCESS AND NO EVIDENCE ON
HEALTHCARE QUALITY.
NEXT SLIDE, PLEASE.
SO THE NEW YORK STATE MEDICAID
VALUE-BASED POLICY WAS
IMPLEMENTED IN 2017 AS PART OF A
LARGER WAIVER, SECTIONS 11-15
DEMONSTRATION AND BPP POLICY WAS
FOCUSED ON HEALTH PLAN PAYMENTS
TO PROVIDERS MODELED ON HCP LAND
FRAMEWORK AND POLICY INCLUDED
SEVERAL TYPES WITH OWN
PERFORMANCE MEASURES.
HOWEVER, MOST PLANS ADOPTED
GENERAL POPULATION CONTRACTS FOR
INDIVIDUALS WITH AVERAGE NEEDS.
THE MEASURES INCLUDED INDICATORS
THAT WERE ARC PREVENTION QUALITY
INDICATORS AND CMS AND OTHERS
WITH HIGHER QUALITY MEASURES
DESIGNATED AS PAY FOR
PERFORMANCE MEASURES AND
PROVIDERS SHARED SAVINGS AND
LOSSES BASED ON PERFORMANCE ON
THOSE P FOR P MEASURES INCLUDED
IN CONTRACTS AND REFERRED TO
ALSO AS INCENTIVE METRICS AND
RELATIONSHIP BETWEEN ACTUAL AND
BUDGETED AGGREGATE COSTS.
NEXT SLIDE, PLEASE.
OUR RESEARCH, AS I SAID, FOCUSED
ON THOSE IMPACTS OF POLICIES AND
BPP POLICIES IN THIS POPULATION
AND HERE WE ARE REPRESENTING OUR
RESEARCH FOCUSED ON THE NEW YORK
STAGE POLICY.
OUR STUDY PERIOD COVERED
PROCEEDING AND FOLLOWING
IMPLEMENTATION OF POLICY WITH
POST IMPLEMENTATION PERIOD AND
POST BPP PERIOD AND DATA SOURCE
INCLUDED A DATA SOURCE ASSEMBLED
BY THE STATE THAT PERMITTED
IDENTIFYING INDIVIDUALS COVERED
BY BPP CONTRACTS AND OUR STUDY
POPULATION WAS ADULTS MEDICAID
ADULT ENROLLEES AND VARIOUS
OUTCOMES INCLUDED ACCESS AND
QUALITY AND EXPOSURE WAS DEFINED
AS COVERAGE UNDER BPP CONTRACT
EVERY YEAR OF POST BPP PERIOD.
OUR APPROACH WAS A DIFFERENCE IN
DIFFERENCE ANALYSIS THAT USED
INTERACTION TERM BETWEEN BPP
EXPOSURE AND POST PERIOD
INDICATORS AS KEY INDEPENDENT
VARIABLE.
NEXT SLIDE, PLEASE.
SO WE -- AS I SAID, WE HAD
VARIOUS OUTCOMES AND HEALTH
ACCESS ANALYSIS FOCUSED ON
AMCRESS TO MENTAL HEALTH CARE
FOR SERIOUS MENTAL ILLNESS.
WE IDENTIFIED INITIATION OF CARE
AS HAVING PARTICULAR POLICY AND
CLINICAL RELEVANCE AND OUR STUDY
COHORT WAS VERY LARGE THAT YOU
CAN SEE THERE OVER 5 MILLION
YEARS WITH 18% BPP EXPOSED.
NEXT SLIDE, MREZ.
MAIN FINDING FROM THIS ANALYSIS
WAS BPP EXPOSURE WAS ASSOCIATED
WITH HALF PERCENTAGE INCREASE IN
ACCESS RELATIVE TO NO EXPOSURE
OVER A BASE RATE OF 22.5%.
THAT WAS A SIGNIFICANT FINDING.
NEXT SLIDE.
IN TERMS OF QUALITY ANALYSIS OUR
OUTCOME WAS QUALITY OF HEALTH
CARE RECEIVED BY ENROLLEES WITH
SERIOUS MENTAL ILLNESS
PRESCRIBING QUALITY WITH 18
MEASURES AND ADULTS WITH SERIOUS
MENTAL ILLNESS AND BOTH
PREVENTION QUALITY INDICATORS
DESCRIBING MENTAL, PHYSICAL, AND
OVERALL HEALTH CARE QUALITY.
OUR STUDY COHORT WAS ALSO VERY
LARGE GIVEN THAT THESE WOULD
ONLY INCLUDE INDIVIDUALS WITH
SERIOUS MENTAL ILLNESS AND 19%
OF WHOM WERE EXPOSE TODAY BPP.
NEXT SLIDE, PLEASE.
MAIN FINDING WAS THAT EXPOSURE
TO BPP WAS ASSOCIATED TO REDUCED
OR UNCHANGED QUALITY VERSUS NO
EXPOSURE AND IMPORTANTLY A THIRD
OF MEASURES 6 OUT OF 18 SHOWED
LOWER PERFORMANCE UNDER BPP AND
INCLUDED PAY FOR PERFORMANCE
METRICS USED AS INCENTIVE
METRICS YOU CAN SEE THERE AND
LARGEST REDUCTIONS WERE OBSERVED
FOR MENTAL HEALTH AND PHYSICAL
HEALTH AND OVERALL HEALTH
QUALITY METRICS. NEXT SLIDE,
PLEASE.
IN SUMMARY FINDINGS FROM OUR
FIRST -- FROM THE FIRST YEAR,
TWO YEARS OF POST IMPLEMENTATION
SUCH AS POSITIVE IMPACTS ON
ACCESS AND NEGATIVE OR NO
IMPACTS ON QUALITY IS DIFFICULT
FOR US TO DETERMINE WHAT MAY BE
DRIVING DIVERGENT RESULTS.
WAIVER THAT BPP POLICY WAS PART
OF SOUGHT TO IMPROVE ACCESS AND
QUALITY OF HEALTHCARE AND
TARGETED ENROLLEES WITH HIGH
BEHAVIORAL NEEDS .
WE SPECULATE THAT SOME DRIVERS
OF DISAPPOINTING QUALITY RESULTS
INCLUDE THAT. MOST ENROLLEES
WITH SERIOUS MENTAL ILLNESS IS
INCLUDED IN GENERAL POPULATION
CONTRACTS AND PERMITTING THIS
POTENTIALLY WORSE PERFORMANCE
AND GIVEN THAT THEY ARE A
RELATIVELY SMALL PROPORTION OF
THOSE CONTRACTS, NOT ALL OF THE
MEASURES THAT WERE RELEVANT TO
THE POPULATION WERE DESIGNATED
AS PAY FOR PERFORMANCE AND SOME
THAT WERE WERE INFREQUENTLY
SELECTED AS INCENTIVE METRICS.
YOU CAN SEE SOME OF THEM THERE
NEXT SLIDE, MREZ.
SO FINALLY, IN TERMS OF POLICY
POTENTIAL POLICY IMPLICATIONS WE
THINK BPP POLICIES SHOULD
EXPLICITLY INCENTIVIZE IMPROVING
ACCESS AND KWALET FOR VULNERABLE
POPULATIONS WITH HIGHER RATES OF
UNMET NEEDS DELIVERING FULLY
INTEGRATED CARE WITH SPECIAL
FOCUS ON INTEGRATING BEHAVIORAL
HEALTH PROVIDERS AND LARGE
GENERAL HEALTH PROVIDERS
ENSURING TIMELY ACCESS TO
PATIENT CARE FOLLOWING ACUTE
CARE AND IMPROVING WORKFORCE
AVAILABILITY AND COMPETENCIES
AND FOR OUTCOMES OF ENROLLEES
WITH SMI AND HONESTLY IMPROVING
CONTRACTS, THEY SHOULD REQUIRE A
MINIMUM OF SMI RELEVANT QUALITY
MEASURES THAT ARE USED IN SHARED
SAVINGS CALCULATION AND
PERFORMANCE REPORTING VULNERABLE
GROUPS INCLUDING THOSE WITH SMI.
ADDITIONALLY PAYERS SHOULD
STRUCTURE PAYMENT FORMULAS TO
PROTECT SAFETY NET PROVIDERS AND
I WILL END HERE AND I HAVE
REFERENCES ALSO.
THANKS VERY MUCH.
>> THANK YOU SO MUCH, DR.
HORVITZ LENNON AND NEXT UP IS
YUHUA BAO FROM CORNELL MEDICINE.
THANK YOU DR. BAO.
>> OKAY. NEXT SLIDE IF YOU CAN
ADVANCE, PLEASE.
>> I DIDN'T GET CONTROL. I WILL
DO THIS AGAIN.
>> YOU SHOULD HAVE CONTROL NOW,
DR. BAO.
>> SOMETIMES IT TAKE AZ SECOND
TO WORK.
THERE YOU ARE.
>> GREAT. THANK YOU. MR. BAO
FROM CORNELL MEDICINE WAS
PREVIOUS TWO WONDERFUL
PRESENTATIONS, THANK YOU. I
WILL TAKE YOU ALL INTO A
RELATIVELY MICROSETTING THAT IS
OPIOID TREATMENT PROGRAMS FOR
METHO DON'T SERVICES.
I WANT TO ACKNOWLEDGE FUNDING
FROM NIDA AND ESPECIALLY POST
DATA TO ACTION NETWORK FOR A
WONDERFULLY COLLABORATIVE TEAM
AT MULTIPLE INSTITUTIONS AND UY
CORNELL AND UCONN AND GOVERNMENT
PARTNER IN OFFICE OF MEDICAID
SERVICES AND SUPPORTS AND FROM
12OTP ORGANIZATIONS IN NEW YORK
STATE PARTICIPATING IN INTERVIEW
STUDY.
BIG PICTURE PROBLEM IS
SUSTAINING EVIDENCE-BASED HOST
PROGRAMS IS CHALLENGING FOR MANY
DIFFERENT REASONS AND ONE OF THE
MAJOR BARRIERS COULD BE LACK OF
MISALIGNMENT OF PROVIDER PAYMENT
AND SO PER SERVICE PAYMENT THAT
IS ALSO KNOWN AS FEE-FOR-SERVICE
PAYMENT MIGHT BE INADEQUATE OR
PROVIDE THE INCENTIVES FOR DOING
WHAT IS RIGHT FOR PATIENTS AND
FAMILIES AND BUNDLE PAYMENT IS A
PROMISING APPROACH THAT IS BEING
INCREASINGLY USED AND SOMETIMES
COULD BE DIFFICULT TO DESIGN AND
OPERATIONALIZE.
HOST PROVIDER ORGANIZATIONS ARE
NO DOUBT A MAJOR STAKEHOLDER AND
MAY LACK EXPERTISE TO ADEQUATELY
ENGAGE IN FINANCIAL SDIGS MAKING
AND TAKE ADVANTAGE OF PAYMENT
INNOVATIONS.
BIG PICTURE PROBLEM THAT TEAM
HAS BEEN WRESTLING WITH IN
RECENT YEARS IS CAN WE DEVELOP
SUPPORT TOOLS TO BENEFIT DIVERSE
DATA AND ORGANIZATIONS AND IN
THAT PROCESS YOU SEE IMMEDIATELY
ENGAGEMENT OF TARGET USERS COULD
BE CRITICAL.
METHO DON'T FOR OPIOID USE IS
AVAILABLE FOR FEDERALLY
CERTIFIED PROGRAMS OR OTPS.
PATIENTS BECAUSE OF VERY
STRINGENT FEDERAL AND STATE
REGULATIONS TYPICALLY HAVE TO
VISIT OTPS ON DAILY OR NEAR
DAILY BASIS TO RECEIVE DOSES
WHILE BEING OBSERVED THAT IS
MEDICATION ADMINISTRATION.
DURING COVID, FEDERAL
REGULATIONS ARE RELAXED TO ALLOW
PATIENTS TO TAKE DOSES HOME.
SUCH FLEXIBILITY WAS MADE
PERMANENT IN APRIL OF 2024
SAMHSA FINAL RULE FOR OTPS AND
EXISTING DATA SUGGESTS THAT
UPTAKE OF TAKE-HOME METHO DON'T
WAS LOW AND VARIED ACROSS OTPS
AND ACROSS STATES AND PRIOR TO
THE PANDEMIC, IT WAS TYPICALLY
PAID AT LEAST IN MEDICAID WITH A
PER SERVICE BILLING OF MEANING
THAT CLINICS COULD ONLY BILL FOR
SERVICES EVERY TIME PATIENT
COMES ON SITE FOR DOSING AND
THAT PAYMENT WAS PREVALENT
BEFORE THE -- BEFORE COVID AND
CHANCES ARE THAT TO OUR EXISTING
KNOWLEDGE IT MAY STILL BE
PREVALENT THESE DAYS AND THAT
COULD CONSTITUTE A SERIOUS
BARRIER TO TAKE-HOME DOSES IF
THEY ARE NOT COVERED AND
ANTICIPATING AND REALLY
ADDRESSING THAT ISSUE, NEW YORK
STATE MEDICAID EARLY ON IN THE
PANDEMIC THAT IS MARCH 2020
IMPLEMENTED A BUNDLED PAYMENT
FOR METHO DON'T AS AN
ALTERNATIVE TO PER SERVICE
PAYMENT AND ALTERNATIVE PER
SERVICE PAYMENT IS CALLED APG OR
AGGREGATE PROVIDER PAYMENT GROUP
AND PAYMENT AS I WILL REFER TO
IT AS LPG AND HERE IS HOW THE
BUNDLE PAYMENT WORKS AND IN ANY
GIVEN WEEK IF THE PATIENT
RECEIVES ANY SERVICES,
ADMINISTRATION TOXICOLOGY OR
MEDICATION MANAGEMENT WITH OR
WITHOUT TAKE-HOME DOSES CLINIC
IS ELIGIBLE FOR FULL BUNDLE THAT
NOWADAYS IN NEW YORK IT IS
ALMOST 20 OR 50 DOLLARS AND SO
AS I MENTIONED THAT THIS BUNDLE
PAYMENT IS AN ALTERNATIVE TO THE
PRE-EXISTING A P. G PAYMENT
MEANING THAT IN ANY GIVEN WEEK
THE CLINIC HAS THE OPTION TO
SUBMIT A BUNDLED BILLING OR
STILL BILL WITH A P. G AND
GIVEN THAT IF A PATIENT COMES ON
SITE IN A WEEK TO RECEIVE A DOSE
AND THAT IS THE ONLY SERVICE
THEY RECEIVE, YOU KNOW, CLINIC
WILL RECEIVE 247 BASED ON BUNDLE
BILLING AND BASED ON APG AND IS
ONLY THE PAYMENT FOR ONE
CLINIC-BASED ON SITE MEDICATION
ADMINISTRATION THAT IS $49.
THE PAYMENT HAS A SECOND TIER
MEDICATION ONLY BUNDLE THAT
MEANS THAT IN THAT WEEK IF THE
PATIENT HAS TAKE-HOME MEDICATION
WITH THEM AND THERE IS NO
ADDITIONAL SERVICE THAT OCCURS,
THE MEDICATION ONLY BUNDLE IS 42
DOLLARS.
COMPARED TO IF IT IS UNDER APG
THE CLINIC CANNOT DO ANYTHING.
THERE IS NO ONSITE SERVICE.
SO YOU NOTICE THERE IS A VERY
SHARP DROP BETWEEN BUNDLE
PAYMENT AND MEDICATION-ONLY
BUNDLE.
IN ANY GIVEN WEEK, OPTIMAL
BILLING STRATEGY THAT IS BUNDLED
VERSUS APG YOU CAN SEE FUNCTION
OF TAKE-HOME SCHEDULE AND
COUNSELING AND IS INDEED VERY
COMPLICATED.
SO EARLY ON IN THE PROJECT THAT
IS FUNDED FROM HD2A CONSORTIUM,
WE NOTICED FROM BILLING DATA IN
NEW YORK STATE THAT MANY OF THE
OTPS WERE NOT BILLING OPTIMALLY
GIVEN AMOUNT OF TAKE-HOMES THEY
ARE DOING AND AT SAME TIME THEY
WERE CONCERNED THAT TAKE-HOMES
WERE HURTING THEM FINANCIALLY.
THE KEY QUESTIONS THAT SEEM TO
COME UP WITH WERE, YOU KNOW, HOW
TO CONDUCT OPTIMAL BILLING AND
YOU KNOW FROM THE PROVIDERS
PERSPECTIVE AND OTHER IS HOW
WILL TAKE-HOMES AFFECT OTP'S
BOTTOM LINE.
THAT GIVES ROOIZE TO THE IDEA OF
DESIGNING OR DEVELOPING A TOOL
TO HELP OTPS TO EXACTLY ADDRESS
THESE TWO NEEDS. FIRST OF ALL,
TO DETERMINE THE OPTIMAL BILLING
STRATEGY GIVEN TAKE-HOME
SCHEDULES AND TO SEE HOW
MEDICAID REVENUE CHAININGS WITH
CHANGES IN TAKE-HOME PRACTICES.
WE WENT TO YOU KNOW BETTER
UNDERSTAND NEEDS AND ALSO TO
INFORM THE TOOL DESIGN WE
INTERVIEWED 12 PROGRAMS AND
ORGANIZATIONS IN NEW YORK STATE
AND BASICALLY MOSTLY INVITED
FINANCIAL LEADERS AND STAFF TO
CONVERSATIONS THAT FOR MANY OTPS
THEIR CLINICAL AND MEDICAL
DIRECTORS JOIN THE CONVERSATION
AND WE ASKED WHAT IS YOUR
EXPERIENCE WITH THE BUNDLED
PAYMENT SINCE MARCH OF 2020?
WE ALSO SHOW THAT PRELIMINARY
TOOL TO SOLICIT THEIR FEEDBACK.
HERE IS WHAT WE LEARNED FROM OUR
CONVERSATIONS. I WON'T READ
THIS SUPPORTING QUOTES.
BUT YOU KNOW THE FIRST THING
THAT CAME UP WAS BUNDLE PAYMENT
OPTION REALLY PROVIDED REVENUE
PROTECTION THAT CONFIRMED TO US
BUNDLED PAYMENT IS A VIABLE
PAYMENT STRATEGY TO SUPPORT
FLEXIBLE TAKE-HOMES AND SECONDLY
YOU KNOW TO OTPS IT WAS
LOGISTICALLY CHALLENGING TO
LEVERAGE ALTERNATIVE PAYMENT
SYSTEM THAT IS A P. G BUNDLED
AND YOU KNOW OVER THE ENTIRE
STATE THERE IS ALMOST ALL OTPS
IN ENTIRE STATES THAT WERE DOING
IT MANUALLY AND THEY WERE
MANUALLY DETERMINING IN A GIVEN
WEEK AND FOR GIVEN PATIENT
SHARING BUNDLE AND BEING
ACTUALLY APG AND IF THEY ARE
ACTUALLY ATTEMPTING THAT.
SO IT REVEALED AND CONFIRMED TO
US DECISION SUPPORT NEEDS
REGARDING OPTIMAL BILLING
STRATEGIES.
AND THIRDLY, SO OTP STAKEHOLDERS
EXPRESSED CONCERN THAT THE
MEDICATION-ONLY RATE IN
TWO-TIERED BUNDLE PAYMENT WAS
PERCEIVED AS LOW AND
UNSUSTAINABLE THAT DOES NOT
DIRECTLY INFORM THE DESIGN OF
THE TOOL. IT DOES POINT OUT TO
A POSSIBLE DIRECTION FOR
REFINING THE BUNDLE PAYMENT
MODEL IF POLICY MAKERS WERE TO
CONSIDER THAT IN THE FUTURE
WHICH IS TO NARROW THE SPREAD OF
THE TWO TIERS TO MITIGATE
PERVERSE INCENTIVES.
OKAY. SO NO. 4, SORRY,
CONSOLING PRACTICES ON WHEN
SUBSTANTIAL CHANGES DURING THE
PANDEMIC AND POSING FINANCIAL
CONCERNS TO OTP ORGANIZATIONS
AND THIS INFORMED REALLY A MAJOR
DESIGN ELEMENT OF OUR TOOL,
WHICH IS THAT OUR REVENUE
CALCULATION WILL HAVE TO TAKE
INTO ACCOUNT CONSOLING
FREQUENCIES AND TOOL UNDERWENT
ITERATIVE UPDATES AND
REFINEMENTS AND WHAT IT LOOKS
LIKE NOW IN SEVERAL SCREENSHOTS
AND FIRST OF AUGUST, ALL THIS
MAJOR PIECE OF HOW BASICALLY
CASE LOAD OF CLINIC IS
DISTRIBUTED ACROSS 10 UNIQUE
SCHEDULES OF TAKE HOME OR PICK
UP SCHEDULES RANGING FROM 7 DAYS
A WEEK TO THEY NEED TO COME ON
SITE SEVEN DAYS A WEEK ALL THE
WAY TO EVERY FOUR WEEKS THAT IS
A TAKE-HOME 28 DAYS OF SUPPLY
AND SECOND PIECE OF INPUT IS
COUNSELING PIECE THAT WEIGHS IN
HEAVILY IMPORTANTLY IN
CALCULATION OF BUNDLE PAYMENT IN
APG AND SEE HERE WE ASK THE USER
TO INPUT AVERAGE INDIVIDUAL AND
GROUP COUNSELING FREQUENCIES AND
CONDITIONAL ON EACH TAKE-HOME
SCHEDULE THIS IS OUTPUT AND
FIRST PART OF THE OUTPUT IS
OPTIMAL PAYMENT STRATEGY FOR
EACH TAKE-HOME AND COUNSELING
SCHEDULE AND SEE HERE IN THE
PARTICULAR SCENARIO IN THIS
CLINIC GIVEN PRACTICES AND
COUNSELING FREQUENCIES PER
SERVICE OR APG PAYMENT GIVES
HIGHER PAYMENT AND SCHEDULE 7
DAYS A WEEK TO 4 DAYS A WEEK AND
STARTING 3 DAYS A WEEK BUNDLE
PAYMENT GIVES OPTIMAL PAYMENT
AND NEXT PART BASICALLY SUMS IT
UP TO ENTIRE CLINIC GIVING
ESTIMATE OF TOTAL ESTIMATED
MEDICAID REVENUE FOR FOUR WEEKS
AND OVER 12 MONTHS IF THE CLINIC
WERE TO BUILD OPTIMALLY EVERY
TIME COMPARED TO APG ONLY AND
BUNDLE ONLY.
THANK YOU. I WILL CONCLUDE MY
PRESENTATION HERE.
>> THANK YOU SO MUCH.
DR. BAO, NOW WE WILL HEAR FROM
DR. JOHN MCCONNELL FROM OREGON
HEALTH AND SCIENCE UNIVERSITY.
DR. MCCONEL?
>> THANK YOU. NOTING CHANGE IN
TITLE HERE AND GIVEN A FEW
OPPORTUNITIES TO GET IT RIGHT ON
AGENDA AND MISSED IT AND MY BAD
AND ORIGINALLY PLANNED TO DO
WORK ON UTILIZATION AND HAD A
LITTLE LAG IN CLAIMS DATA THAT
IS EASIER TO GET DATA ON BED
CAPACITY AND PROJECT WE WERE
WORKING ON AND WHAT I WANT TO
PRESENT AND RESEARCH IS
SUPPORTED FROM GRANT BY NIMH AND
LOOKING AT SEMIWAIVERS AND
GRATEFUL FOR SUPPORT. NEXT
SLIDE, PLEASE.
SO WHAT ARE SMI AND SMD WAIVERS
AND SERIOUS ILLNESS AND
EMOTIONAL DISTURBANCES FOR
CHILDREN? 1965 FEDERAL LAW
PROHIBITED MEDICAID FUNDS AGES
21 TO IN INSTITUTIONS FOR MENTAL
DISEASES IMDS AND FACILITIES
WITH MORE THAN 16 BEDS
SPECIALIZING IN BEHAVIORAL
HEALTH TREATMENT. EXCLUSION HAS
INHIBITED ACCESS TO PATIENT
PSYCHIATRIC CARE FOR MEDICAL
ENROLLEES FEELING IT IS
COMPARITIABLE WITH -- PEOPLE ON
ONE SIDE WANT THIS EXCLUSION TO
BE REMOVED FEELING IT IS
CRITICAL TO SIGNAL PARODY FOR
ALL SERVICES AND THOSE CONCERNED
ABOUT ANY USE OR EXPANSION OF
IN-PATIENT PSYCHIATRIC CARE
FEELING NOT EVIDENCE-BASED
TREATMENT THAT THEY WORRY ABOUT
SHIFT FROM OUT-PATIENT TO
IN-PATIENT AND NEXT SLIDE,
PLEASE.
SO TO DEAL WITH THE EXCLUSION IN
[INDISCERNIBLE] ALLOWED STATE TO
APPLY FOR A WAIVER THAT THEY
COULD RECEIVE FEDERAL MATCHING
FUNDS FOR SPECIAL TREATMENT IN
IMDS AND LIMITATIONS HERE AND
YOU ARE ONLY ALLOWED TO GET PAID
FOR PEOPLE THAT STAY FOR 60 DAYS
OR LESS AND AVERAGE STAY ACROSS
ALL MEDICAID ENROLLEES HAS TO BE
30 DAYS OR LESS AND IMPORTANT
MILESTONES HERE DESIGNED TO MAKE
SURE STATES ARE NOT JUST
FOCUSING ON IN-PATIENT CARE AND
SOME ENCOURAGE OUTPATIENT
SERVICE AND OTHER THINGS AND
THIS WAIVER LOOKS SIMILAR IN
LANGUAGE AND FEEL IT IS
DIFFERENT THAN 2015 WAIVERS
FOCUSING ON SUBSTANCE USE
DISORDER TREATMENT.
NEXT SLIDE, PLEASE.
TO GIVE YOU SOME IDEA OF TAKE UP
ON TWO WAIVERS YOU CAN SEE HERE
BLUE STATES ARE STATES THAT HAVE
SUD, IMD WAIVER AND ORANGE
STATES HAVE BOTH WAIVERS AND ONE
IN ALABAMA SMDI WAIVER AND TWO
THINGS TO NOTICE HERE. THOSE
WITH WAIVER HAVE SUD WAIVER AND
CAME BEHIND TOGETHER AND NEVER
DID SMI WAIVER AND THERE IS ONE
STATE WITH SMI WAIVER AND UPTAKE
IS HIGHER FOR STATES TAKING SUD
WAIVERS AND SMI WAIVERS AND 36
STATES HAVE DONE WAIVERS AND 13
HAVE DONE SMI WAIVERS AND WERE
INTRODUCED LATER AND UPTAKE HAS
BEEN SLOWER.
NEXT SLIDE, PLEASE.
SO WHY ARE WE INTERESTED IN BED
CAPACITY? WE HAVE GOTTEN
QUESTIONS FROM LEGISLATORS AT
FEDERAL AND STATE LEVEL ASKING
ABOUT WAIVERS WONDERING IF IT
CAN HELP INCREASE PATIENT
CAPACITY GENERAL CONSENSUS
SHORTAGE OF PSYCHIATRIC BEDS
CONTROVERSIAL AND IN SOME STATES
IS A LARGE CONCERN AND THAT
DECLINE IF YOU CAN BELIEVE IT
CAN BE TRACED TO
DEINSTITUTIONALIZATION EFFORTS
SPANNING MORE THAN 50 YEARS AND
BIG CONCERNS PATIENTS ARE
BOARDED IN EMERGENCY DEPARTMENTS
AND WE HAVE ONGOING WORK IN THE
GRANT WHERE WE LOOK AT BOARDING
RATES FOR MEDICAID ENROLLEES TO
SHOW UP AND THOSE WITH MENTAL
HEALTH CONDITIONS AND AVERAGE
LIKELIHOOD THAT YOU ARE PROBABLY
BEING BOARDED IS 1 IN 10 THAT IS
HIGH ACROSS STATES AND SOME
STATES 5 OR 6 STATES IS MORE
THAN 2 OUT OF -- SORRY MORE THAN
1 OUT OF EVERY 5 PATIENTS OR
MEDICAID ENROLLEES SHOWING UP IN
EMERGENCY DEPARTMENT AND MENTAL
HEALTH CONDITION STAYING THERE
LONGER THAN THREE DAYS THAT IS
PRETTY CONCERNING AND SOME
PEOPLE THINK THAT EXPANDING IN
PATIENT CAPACITY COULD REDUCE
BOARDING AND WE WANT TO ADDRESS
ABILITY TO SEE IF WAIVERS HAVE
INCREASED ABOUT ED CAPACITY YET.
NEXT SLIDE, PLEASE.
LOOKING AT DIFFERENT DATA
SOURCES MEDICARE PROVIDED
SERVICE GIVING INFORMATION ON
INFORMATION FOR BED COUNTS
PRESTANDING PATIENT PSYCHIATRY
AND A FEW DATA POINTS
DESCRIPTIVE TO GIVE IDEA WHAT IS
HAPPENING HERE AND HAVE DONE
QUALITATIVE FOCUS ON THIS GRANT
AND HAVE DONE INTERVIEWS WITH
PROVIDERS ADVOCATES AND MCOS TO
UNDERSTAND HOW THEY ARE VIEWING
WAIVERS AND MAIN ANALYSIS HERE
SHOWING DIFFERENCE OF DIFFERENCE
AND 13 STATES ADOPTED THIS
WAIVER DOING IT AT DIFFERENT
TIMES AND LOOKING AT STAGGERED
ROLLOUT AND WE ARE USING THIS TO
ADDRESS DIFFERENTIAL TIMING AND
ANALYSIS AND ALLOWING TO TEST
FOR HETEROGENEITY ACROSS STATES
AND OVER TIME AND NEXT SLIDE,
PLEASE.
MIGHT HAVE DUPLICATED NEXT
SLIDES PLEASE SO NEXT ONE.
KEEP GOING. THIS IS DESCRIPTIVE
DATA AND GIVING SENSE WHERE BED
GROWTH IS HAPPENING MEASURING IN
PROVIDER SERVICE DATA WE CAN
MEASURE FREE STANDING
PSYCHIATRIC HOSPITALS AND HARD
TO MEASURE AND EXTENT THERE HAS
BEEN GROWTH NATIONALLY IT HAS
BEEN IN THIS AREA AND
RESIDENTIAL BEDS HAVE BEEN
DECLINING AND OTHERS RELATIVELY
FLAT AND GROWTH FOR FREE
STANDING IN PSYCHIATRIC PATIENT
HOSPITAL AND FOR THIS GROUP TO
UNDERSTAND CHANGES. NEXT SLIDE,
PLEASE.
WE SEE LOTS OF VARIATION HERE IN
BED CAPACITY AND KIND OF LOOKING
AT THREE MEASURES ONE IS OVERALL
BEDS COMMUNITY HOSPITALS PER
HUNDRED THOUSAND POPULATION
LOOKING ACROSS STATES 10TH TO
NINETIETH PERCENTILE TAKING THAT
ONE MEASURE VARIATION 2.0 AND
KNOW THERE IS BED VARIATION OF
BED SUPPLY ACROSS STATES NOT TOO
SURPRISING GIVING YOU IDEA AND
LOOKING AT FREE STANDING
PSYCHIATRIC HOSPITALS PER
HUNDRED THOUSAND THEY ARE
SMALLER AND GREATER VARIATION
NINETIETH AND 10TH PERCENTILE
GOING FROM 2 TO 5 AND MEDICAID
AVAILABLE IMD BEDS AND THOSE
THAT DO AND IN DATA AND LOOKING
AT THOSE BEDS AND 100,000
MEDICAID ADULT ENROLLEES YOU SEE
LARGER VARIATION HERE.
THERE IS A LOT OF DIFFERENCE
HERE IN HOW -- WHAT CAPACITY
STATES HAVE ACROSS THESE
PARTICULAR MEASURES.
NEXT SLIDE, PLEASE.
SHOWING YOU FREE STANDING
PSYCHIATRIC BEDS -- GIVING YOU
VARIATION ACROSS STATES.
NEXT SLIDE.
ONE QUESTION IS ARE STATES WITH
LOWER BED CAPACITY MORE LIKELY
TO APPLY FOR SMI WAIVERS WE
DON'T HAVE FINDING IN THAT 50
STATES NOT SUPER HIGH POWERED
THERE MEASURES OF BED CAPACITY
THERE AND OTHER TYPES OF THINGS
WE THOUGHT MIGHT EFFECT DECISION
TO APPLY FOR ONE WAIVER AND
MEDICAID ENROLLMENT AND MCO
PENETRATION AND MEASURES OF
MENTAL HEALTH NEED AND
PREVALENCE AND WE DON'T SEE
ANYTHING THAT LOOKS MODESTLY
CORRELATED FOR DECISIONS TO
PURSUE WAIVERS AND CORRELATES
HERE WITH INTERVIEWS SOME STATES
FEEL THEY HAVE CAPACITY TO DO
THIS AND GO FOR IT AND SOMETIMES
DON'T AND NOT STRATEGIC AND
BASED ON PARTICULAR THINGS
HAPPENING IN THE STATE AS FAR AS
WE CAN TELL.
NEXT SLIDE.
HERE ARE RESULTS FROM DIFFERENCE
AND DIFFERENCE ANALYSIS AND
WON'T GO INTO ALL OF THE METHODS
BUT RUNNING RESULTS HERE. WE
ARE LOOKING AT A FEW DIFFERENT
COMPARISON GROUPS AND FIRST IS
STATES DOING SMI WAIVERS
COMPARED TO ALL OTHER STATES AND
OUTCOMES ARE LOOKING AT FOUR
DIFFERENT OUTCOMES AND ONE BIG
OUTCOME AND THREE THAT ARE A
SUBSET OF THAT AND BEDS IN IMDS
THAT ACCEPT MEDICAID AND DON'T
SEE ANYTHING SIGNIFICANT AND
DECREASE AMONG STATES PER
HUNDRED THOUSAND INDIVIDUALS AND
SLIGHT DECREASE IN STATES
ADOPTING WAIVERS AND LOOKING AT
RURAL IMDS YOU WOULD PERHAPS SEE
MORE CHANGES THERE AND DON'T SEE
CHANGES DECREASE SAME FOR IMDS
THAT PROVIDE SUD TREATMENT AND
ONE PAPER SUGGESTING IMDS THAT
DO BOTH SUD AND SMI TREATMENT
THAT ARE MORE LIKELY TO ADOPT
WAIVERS AND DON'T SEE THAT.
AND NO CHANGE IN FOR PROFIT BEDS
AND SOME LITERATURE SUGGESTING
FOR PROFIT CENTERS ARE LIKELY TO
RESPOND POSITIVELY AND DON'T SEE
CHANGE.
NEXT SLIDE, RUNNING COMPARISON
AGAINST OTHER STATES THAT DIDN'T
HAVE WAIVERS AND EXCLUDES STATES
WITH SUD WAIVERS AND LOOKED AT
STATES WITH SUD WAIVERS
COMPARING THEM TO STATES WITHOUT
WAIVERS AND CAN'T PICK UP SIGNAL
HERE FOR BWAIVERS DRIVING INCRE
IN BEDS.
NEXT SLIDE. ARE QUESTIONS HERE
OPTIMALLY DESIGNED? WE SEE
UPTAKE IS SLOWER THAN SUD
WAIVERS AND CONCERNS FROM STATE
ADMINISTRATORS 30 DAY AVERAGE
LENGTH OF STAY IS RESTRICTIVE
AND DOESN'T MATCH CLINICAL
EVIDENCE AND HAVING SOMEBODY
WITH SERIOUS MENTAL ILLNESS AND
HOSPITAL ADMISSION THAT SORT OF
SAYING THEY CAN ONLY STAY FOR 30
DAYS DOESN'T MEET CLINICAL NEEDS
OF PATIENT AND THERE SEEMS TO BE
CONCERN THAT ADMINISTRATIVE
BURDEN IS HIGH FOR SUD WAIVERS
AND WHY STATES ARE NOT ALWAYS
PURSUING THOSE AND THINK A LOT
OF CONCERN THAT FOCUS ON IN
PATIENT BEDS DISTRACT FROM NEED
TO LOOK AT LARGER CONTINUUM OF
CARE WITH STEP DOWN BEDS.
NEXT SLIDE.
WE WONDER ABOUT THE WAIVER
KNOWING THERE IS MENTAL HEALTH
CRISIS OUT THERE AND IMD
EXCLUSION IS A THORN IN THE SIDE
FOR SOME BUT IT IS YOU KNOW
REALLY ONLY PART OF THE PROBLEM.
IT IS A LITTLE BIT OF A FUNNY
THING TO HAVE THESE SMI/SMD
WAIVERS AND ADDRESS A SMALL PART
OF THE MENTAL HEALTH CONTINUUM
AND WONDER ABOUT IF WE WANT TO
USE MEDICAID TO DRIVER CHANGE
HERE LOOKING AT WAIVERS THAT
HAVE GONE OUT OF FASHION HERE
AND TIED TO SPECIFIC PERFORMANCE
METRICS AND IMPROVING CARE
DELIVERY ALLOW STATES TO USE
LOCAL CONTEXT HERE FOCUSING ON
OUTCOMES RATHER THAN ANCRIMINAL
ISSUE THAT IS INPATIENT BEDS.
NEXT SLIDE.
THINKING A GREAT OPPORTUNITY
HERE MEDICAID IS LARGEST PAYER
FOR MENTAL SERVICES OPPORTUNITY
TO ADDRESS MENTAL HEALTH IN
LARGE POPULATION AND DIRECT
RESPONSE IS WARRANTED RATHER
THAN FOCUSING ON NARROW SLICE OF
CONTINUUM OF CARE. THANK YOU.
>> THANK YOU SO MUCH, DR.
MCCONEL.
NEXT UP IS DR. CARA ZIBBON FROM
UNIVERSITY OF MICHIGAN.
DR. ZIBBON?
>> THANK YOU EVERYONE FOR HAVING
ME HERE TODAY.
NEXT SLIDE.
I WANTED TO GIVE CONTEXT FOR
WORK I WAS GOING TO PRESENT THAT
IS FUNDED BY NATIONAL INSTITUTE
OF HEALTH INCLUDING NIMH AMONG
OTHERS SHOWN HERE AND RESULTS I
WILL PRESENT TODAY ARE FROM
FIRST STUDY CALLED MATERNAL
BEHAVIOR HEALTH POLICY
EVALUATION STUDY WHERE WE
FOCUSED ON POLICIES EFFECTING
PERINATAL MOOD ANXIETY DISORDER
AND DETECTION AND TREATMENT AND
SEEING HERE WE LOOKED AT OTHER
CONDITIONS INCLUDING SUBSTANCE
USE DISORDER AS WELL AS MATERNAL
MORBIDITY AND MORTALITY AND NEXT
SLIDE, PLEASE.
SO TODAY I WILL SHARE FINDINGS
FOR ONE PARTICULAR PAPER WE DID
LOOKING AT PERINATAL
PSYCHOTHERAPY USED IN BEFORE AND
AFTER TWO DIFFERENT HEALTH
POLICIES AND LINK IS HERE.
NEXT SLIDE.
SO AS WE HAVE BEEN TALKING ABOUT
INSURANCE COVERAGE CAN IMPACT
HEALTH CARE ACCESS FOR MANY
DIFFERENT GROUPS OF PEOPLE THAT
INCLUDES OBVIOUSLY PEOPLE WITH
PERRI NATAL MOOD ANXIETY
DISORDERS SEEKING TO LOOK AT HOW
BOTH MENTAL HEALTH PARITY AND
AFFORDABLE CARE ACT IMPACTED
THESE POPULATIONS AND BOTH COULD
REPRESENT POLICIES THAT COULD
HAVE IMPROVED ACCESS TO MENTAL
HEALTH CARE THAT IS A NATURAL
EXPERIMENT THAT COULD CHANGE
ACCESS TO TREATMENT AND WE KNOW
THAT IN THIS POPULATION THERE
ARE MANY BARRIERS TO DIAGNOSIS
TREATMENT AND TREATMENT AND
HEALTH IMPROVEMENTS.
NEXT SLIDE, PLEASE.
SO SPECIFICALLY WE WANTED TO
UNDERSTAND WHAT ARE THE
ASSOCIATIONS BETWEEN MENTAL
HEALTH PARODY AND AFFORDABLE
HEALTH CARE ACT AND IN THIS
ANALYSIS WE DOESN'T FOCUS ON
CRYTOTROPIC -- LOOKING AT
DELIVERING WOMEN OVERALL AS WELL
AS SUBSET OF THOSE SPECIFICALLY
WITH [INDISCERNIBLE].
NEXT STEP OR SLIDE.
IN OUR DATA WE ESTIMATED CHANGES
IN BOTH ANY PSYCHOTHERAPY USED
AS WELL AS PER VISIT OUT OF
POCKET COSTS FOR PSYCHOTHERAPY
ASSOCIATED WITH TWO POLICIES
THAT WE USED COMMERCIALLY
INSURED POPULATION BETWEEN 20 --
2007 AND 2019 ACROSS STATES OF
REPRODUCTIVE AGED WOMEN DEFINED
BY CDC USING CONTINUOUS PLAN AND
ENROLLMENT IN THE YEAR AND
DELIVERY AND STATE OF SOURCE IS
OPTIMUM DATA.
NEXT SLIDE.
USING INTERRUPTED TIME SERIES
ANALYSIS TO ASSESS CHANGES IN
PSYCHOTHERAPY VISIT COSTS YEAR
BEFORE AND AFTER DELIVERY AND
CODES TO IDENTIFY PSYCHOTHERAPY
AND USING COPAYMENTS COINSURANCE
AND DEDUCTIBLES FOR
PSYCHOTHERAPY VISITS TIED TO
2019 ADJUSTED INFLATION DOLLARS.
NEXT SLIDE, PLEASE.
WE HAD FOUR INDEPENDENT
VARIABLES INTERESTED TO FOCUS ON
LEVEL CHANGES BEFORE AND AFTER
POLICY CHANGES AND TWO FOCUSING
ON SLOPE CHANGES OVER TIME
BETWEEN EACH POLICY CHANGE.
WE INCLUDED PLANS WITH EVIDENCE
OF ANY COVERAGE BASED ON --
BECAUSE WE DIDN'T HAVE BENEFIT
DESIGN INFORMATION.
NEXT SLIDE, PLEASE LOOKING AT
THREE TIME PERIODS BEFORE BOTH
POLICIES. ONE SECOND TIME
PERIOD LOOKING AFTER MENTAL
HEALTH PARODY BEFORE ACA AND
THIRD BEFORE IMPLEMENTATION OF
POLICIES ACCOUNTING FOR PATIENT
DEMOGRAPHIC AND CHARACTERISTIC
SHOENZ HERE AGE AND RACE
ETHNICITY AND GEOGRAPHIC REASON
AND INSURANCE -- MODE OF
DELIVERY AND DIAGNOSIS OF
COMORBID MENTAL HEALTH AND
PHYSICAL HEALTH CONDITIONS.
NEXT SLIDE, PLEASE.
SO HERE, THE FIRST SLIDE I'M
SHOWING IS AMONG ALL DELIVERING
INDIVIDUALS NOT JUST PEOPLE WITH
MENTAL HEALTH CONDITIONS THAT
INCLUDED OVER 800,000 DELIVERIES
AMONG 700,000 WOMEN.
AS YOU CAN SEE HERE WITH DARKEST
LINE AT THE TOP AND MENTAL
HEALTH PARITY DID NO THE HAVE
STATISTICALLY SIGNIFICANT
IMMEDIATE OR SUSTAINED IMPACT ON
THOSE WHO USE PSYCHOTHERAPY AND
ACA DID NO THE HAVE IMMEDIATE
IMPACT AND AFTERWARDS IT
INCREASED OVER TIME PROPORTION
OF INDIVIDUALS THAT HAD
PSYCHOTHERAPY. AGAIN, NOTE HERE
THIS IS AMONG ALL DELIVERIES NO
THE JUST PEOPLE WITH MENTAL
HEALTH CONDITIONS.
NEXT SLIDE, PLEASE.
HERE WE LIMITED OUR SAMPLE TO
OVER 100,000 WOMEN WITH
PERINATAL MOOD ANXIETY DISORDERS
AND HERE WE SEE PARITY LEADED TO
IMMEDIATE DECREASE INCREASE IN
PSYCHOTHERAPY RECEIPT AND AFTER
THIS SAW IMMEDIATE AND SUSTAINED
INCREASES IN USE OF
PSYCHOTHERAPY.
NEXT SLIDE.
HERE, THIS IS THE FINDINGS FROM
BOTH GROUPS.
THEY WERE VERY SIMILAR AND AMONG
ALL DELIVERING WOMEN AND AMONG
THOSE WITH PERINATAL MOOD
ANXIETY DISORDERS AND I'M
SHOWING THIS ONCE.
THIS IS A BIT OF A NOISY SLIDE
THAT IS THE MAIN FOCUS OF WHY
I'M HERE TODAY.
I WANTED TO JUST EXPLAIN THAT
THESE LARGE VARIATIONS WE CAN
SEE THAT I BELIEVE HAS TO DO
WITH DEDUCTIBLES AT BEGINNING OF
ANY YEAR THAT PEOPLE WILL HAVE
MORE OUT OF POCKET COSTS UNTIL
THEY MEET THEIR DEDUCTIBLE.
PURPLE LINE DASHED GOING
HORIZONTALLY IS SHOWING THAT OUT
OF POCKET PAYMENTS DECREASED
AFTER MENTAL HEALTH PARITY
IMPLEMENTATION WITH IMMEDIATE
AND SUSTAINED INCREASE AFTER THE
ACA MRAF NEXT SLIDE, PLEASE.
SO WHY DO WE THINK THIS MIGHT
HAVE HAPPENED?
THERE IS A NUMBER OF DIFFERENT
REASONS FOR FINDINGS
POTENTIALLY. PARITY AND ACA AS
WELL LED TO POTENTIALLY INCREASE
IN DEMAND FOR ACCESS TO
TREATMENT AND NOT NECESSARILY
INCREASE OF SUPPLY OF PROVIDERS
AND WE KNOW THAT THERE IS A
SHORTAGE OF MENTAL HEALTH
PROVIDERS NATIONWIDE.
WE ALSO KNOW THAT THERE WAS A
NUMBER OF VIOLATIONS OF MENTAL
HEALTH PARITY AND FINDINGS MIGHT
HAVE BEEN BIASED TOWARDS NULL.
WE INCLUDED INDIVIDUALS WITH
OTHER MENTAL HEALTH CONDITIONS
AND THINK THAT BENEFITS OVER
TIME FROM AFFORDABLE CARE ACT
MIGHT HAVE BEEN BECAUSE OF A
DECREASING NUMBER OF
GRANDFATHERED PLANS OVER TIME
AND WE THINK THERE MIGHT BE
INCREASE IN USE OF HIGH
DEDUCTIBLE PLANS THAT COULD HAVE
IMPACTED OUT OF POCKET PAYMENTS.
ONE OTHER THING TO NOTE IS ALL
OF THE ANALYSIS SHOWN HERE WERE
CONDUCTED PRIOR TO THE PANDEMIC
AND IT LED TO INCREASE IN USE OF
TELEMENTAL HEALTH SERVICES
EXTENDING STUDY AND HAVING
AVAILABLE DATA TO DO SO WE MIGHT
HAVE SEEN PATTERNS AND IF SO
BASICALLY PAPER SHOWED SOME
MIXED FINDINGS ON CHANGES AND
ACCESS TO THERAPY AND OUT OF
POCKET PAYMENT AMONG DELIVERING
INDIVIDUALS AND THAT THESE WERE
COMPLEMENTARY AND COMPLEX
IMPACTS OF POLICIES ON MATERNAL
MENTAL HEALTH CARE AND USING A
FEW MINUTES OF REMAINING TIME TO
POINT TO WORK WE DO IN PERINATAL
MENTAL HEALTH SERVICES AND
POLICY PROGRAM AND HERE POLICIES
IS DOING LOTS OF THE WORK.
OTHER PROGRAMS FOCUS MORE ON
CLINICAL TREATMENT AND TEAM IS
RECENTLY USING THIS DATA TO PUT
OUT PROFILES WHERE WE HAVE
LOOKED AT A VARIETY OF DIFFERENT
SUBCHARACTERISTICS OF PEOPLE
WITH MENTAL HEALTH CONDITIONS
AND THIS IS A EXAMPLE FROM
MICHIGAN AND WE HAVE DONE THEM
FOR ALL STATES.
YOU CAN SEE THE LINK BELOW.
WE BELIEVE THAT ACCESSING
MATERNAL MENTAL HEALTH DATA CAN
HELP INFORM POLICY AND PRACTICE
GOING TO THE NEXT SLIDE YOU WILL
SEE INITIAL PAGES WHERE WE HAVE
AGGREGATED A VARIETY OF
DIFFERENT PUBLICLY AVAILABLE
DATA SOURCES AND AGAIN IS
MICHIGAN AND HAVE DONE FOR ALL
STATES ON ACCESS TO PROVIDERS
AND MENTAL HEALTH ELSEWHERE AND
GOING TO THE LINKS YOU CAN SEE
VARIETY OF DIFFERENT DATA
SOURCES AND ON NEXT SLIDE WE
SHOWED THAT WE ACTUALLY
CONDUCTED USING A DASHBOARD WRU
CAN CLICK ON MAPS AND SEE NOT
ONLY VARIATION BY STATE AND BY
TIME OF PERINATAL MENTAL HEALTH
CONDITIONS BUT CAN SEE SUBSETS
AND HERE WE ARE SHOWING
INDIVIDUALS WITH SUICIDAL
IDEATION.
NEXT SLIDE.
I WANT TO ACKNOWLEDGE MY
COLLABORATORS AND FUNDERS FOR
THIS WORK.
NEXT SLIDE.
THANK YOU.
>> THANK YOU SO MUCH, DR. ZIVIN.
FINAL PRESENTER IS DR. NICOLE
MAESTAS FROM HARVARD MEDICAL
SCHOOL. DR. MAESTAS.
>> THANK SO YOU MUCH. I TRUST
YOU WILL STOP ME IF YOU CAN'T
HEAR ME.
THIS PROJECT LOOKS WE WILL TAKE
A STEP BACK FOR PAYMENT MODELS
FOR A MOMENT AND THINK HARDER
ABOUT WHERE FACILITIES ARE
LOCATED RELATIVE TO POPULATIONS
THEY SERVE.
NEXT SLIDE, PLEASE.
MOTIVATION HERE IS THE SIMPLE
FACTS THAT ONE IN 5 ADULTS
SUFFER FROM MENTAL ILLNESS AND
FEWER THAN HALF RECEIVE
TREATMENT AND ARE LONG DELAYS
BETWEEN SYMPTOM ONSET AND
TREATMENT AND IN ADDITION UNMET
NEEDS ARE HIGHER IN CERTAIN
POPULATIONS THAN OTHERS AND
THOSE POPULATIONS MAY BE
DISTRIBUTED GEOGRAPHICALLY IN
WAYS THAT MAKE THE PROVIDER
LANDSCAPE I WILL EXPLAIN WHAT I
MEAN BY THAT IN A MOMENT
PARTICULARLY RELEVANT FOR THEM.
THERE IS VERY LITTLE RESEARCH
ABOUT PROVIDER LANDSCAPE.
BY THAT I MEAN THE NUMBER,
LOCATION, ORGANIZATION, AND THE
FINANCING OF HEALTH CARE
PROVIDERS ACROSS THE COUNTRY.
NEXT SLIDE, PLEASE.
THE PROJECT HERE THAT WE ARE
CALLING OUR PROVIDER LANDSCAPE
PROJECT AIMS TO REALLY
CHARACTERIZE THE US PROVIDER
LANDSCAPE IN TERMS OF VARIATIONS
AND ACCESS TO MENTAL HEALTH CARE
SERVICES AND ALSO THEN ANALYZE
CAUSAL IMPACTS OF CERTAIN
FEATURES OF THAT LANDSCAPE AND
CHANGES IN POLICY AND NOTABLY
MEDICAID POLICY AND OTHER
POLICIES THAT MAY ALTER THE
SPATIAL DISTRIBUTION OF
FACILITIES.
AND WHO CAN ACCESS THEM.
APPROACH WILL ULTIMATELY BE TO
BRING IN QUASI EXPERIMENTAL
RESEARCH DESIGNS APPLYING THEM
TO DIFFERENT POPULATIONS BEING
OBSERVED IN LARGE DATA BASES
SUCH AS COMMERCIALLY INSURED OR
MEDICAID OR MEDICARE PATIENTS
LEVEL PROVIDER ORGANIZATION AND
OWNERSHIP DATA AS WELL. TODAY I
WILL SHOW YOU WE ARE STILL AT
THE BEGINNING OF THE WORK AND
WILL SHOW YOU PORTRAITS AND
FINDINGS SO FAR OF THE PROVIDER
LANDSCAPE.
NEXT SLIDE.
SO OUR SPECIFIC QUESTIONS FOR
TODAY WILL BE SIMPLY WHAT SHARE
OF THE US POPULATION LIVES
WITHIN A REASONABLE DRIVING
DISTANCE FROM A MENTAL HEALTH
FACILITY?
DOES GEOGRAPHIC ACCESS VAR WHY I
BY INDIVIDUAL AND COUNTY
CHARACTERISTICS?
I WILL ALSO SHOW YOU ONE SLIDE
WHERE WE EXPLORE WHERE
GEOGRAPHIC ACCESS TO MENTAL
HEALTH FACILITIES TENDS TO
CORRELATE WITH MENTAL HEALTH
NEEDS IN THE POPULATION.
NEXT SLIDE.
PLEASE NEXT SLIDE AND USING
SEVERAL DATA BASES I WON'T GO
INTO THE DETAILS OF BUT FIRST
AND PROMINENT ONE IS MENTAL
HEALTH TRACKING REPOSITORY DATA
ON MENTAL HEALTH FACILITY
LOCATIONS AND THEY ARE BROAD AND
COVER EVERYTHING FROM COMMUNITY
MENTAL HEALTH CENTERS TO IN
PATIENT HOSPITALS OF DIFFERENT
TYPES AND OUTPATIENT CARE
FACILITIES AND FACILITIES THAT
ARE A BLENDED MIX OF IN-PATIENT
AND OUT-PATIENT AND BRINGING
CENSUS DATA TO BEAR AND
DEPRESSION PREVALENCE MEASURES
FROM BIRTH RATES AND HEALTH
AMERICA. NEXT SLIDE, PLEASE.
HERE IS A EXAMPLE OF PRIMARY
METHOD WE ARE USING TO
CHARACTERIZE ACCESS AND PICTURE
ON THE RIGHT SHOWS A COUNTY
COMPOSED OF TWO CENSUS TRACTS,
TRACTS 1 AND TRACT 2. BLACK DOT
IN MIDDLE OF THE RED SPLOTCHES
ARE MENTAL HEALTH FACILITIES AND
RED SPLOTCH DEFINES A POLYGON
AROUND EACH FACILITY THAT IS
DENOTING A DRIVING DISTANCE FROM
THE FACILITY AND LOOKING HERE AT
AN EXAMPLE OF A 20-MINUTE
DRIVING DISTANCE FROM THE
FACILITY. YOU CAN SEE DRIVING
DISTANCE IS NICE. YOU DON'T
WIND UP WITH PERFECT CIRCLES
AROUND A FACILITY THAT WILL BE
KIND OF CLOSE FLY DISTANCE AND
YOU ACTUALLY GET DRIVING
DISTANCE THAT FACTORS IN ROADS
AND ROAD CONDITIONS AND TRAFFIC
CONDITIONS, ET CETERA.
WE USE RTIS PRO HE TO CONSTRUCT
POLYGONS AROUND EVERY FACILITY
ACROSS CENSUS TRACTS AND TO
CHARACTERIZE SHARE OF THE
POPULATION THAT LIVES WITHIN
DRIVING DISTANCE THAT WE CAN DO
IT AT THE POPULATION OVERALL FOR
CENSUS TRACK AND BY DIFFERENT
POPULATION GROUPS SLIDE.
OKAY. WE WILL ALSO DO
CORRELATION ANALYSIS AND WON'T
GET INTO DETAILS OF THOSE GIVEN
TIME. THEY ARE SIMPLY TO SHOW
WHETHER NEED MATCHES ACCESS
ACROSS COUNTIES IN THE US AND
THESE PICTURES WILL AND FIGURES
HAVE A VARIETY OF CONTROL
VARIABLES IN THEM NONTHE
WILLINGS ARE ASSOCIATION AND
WILL GET INTO IT IN A MOMENT.
NEXT SLIDE.
OKAY. NEXT SLIDE, PLEASE.
OKAY. SO OUR FIRST FINDING IS
ACCESS IS HIGH AND IN MOST
PLACES EXCEPT FOR RURAL AREAS
AND I WILL FIRST SHOW YOU
20-MINUTE DRIVE DISTANCE AND WE
WILL LOOK AT 60-MINUTE DRIVE.
WHAT YOU ARE SEEING HERE IS A
MAP OF CENSUS TRACKS WHERE WE
CODED SHARE OF TRACK AREA AND
JUST PHYSICAL AREA WITHIN A
20-MINUTE DRIVE TO A FACILITY.
OKAY?
FROM THIS DATA WE CAN ROLL IT UP
AND ESTIMATE THAT 83.9% OF
INDIVIDUALS IN THE COUNTRY LIVE
WITHIN A 20 MINUTE DRIVE OF A
MENTAL HEALTH FACILITY AND
BREAKING IT DOWN TO TRACK LEVEL
WE SEE FOR EXAMPLE 50 -- 18%
HAVE 50% OR LESS OF AREA WITHIN
A 20 MINUTE DRIVE AND 72% HAVE
MORE THAN A 90% SHARE OF THEIR
AREA WITHIN A 20 MINUTE DRIVE.
THERE IS VARIATION ACROSS
TRACKS.
OVERALL, A VERY HIGH PROPORTION
OF INDIVIDUALS LIVE WITHIN A 20
MINUTE DRIVE. NEXT SLIDE.
NOW YOU CAN REALLY SEE THE
DIFFERENCE WHEN WE LOOK AT 60
MINUTE DRIVE FROM A FACILITY AND
IN THIS VIEW NEARLY EVERYONE IN
THE COUNTRY HAS A FACILITY OF
ANY TYPE WITHIN A 60-MINUTE
DRIVE.
97.7% OF INDIVIDUALS.
THERE IS STILL SOME VARIATION AT
THE TRACK LEVEL WHERE SOME
TRACKS ARE VIRTUALLY ENCOMPASSED
WITHIN 60-MINUTE DRIVE FROM A
FACILITY BUT TRACKS ARE PORTIONS
OF THEIR AREA THAT ARE NOT
SERVED BY EVEN A 60-MINUTE
DRIVE.
NEXT SLIDE.
BREAKING THIS OUT BY DEMOGRAPHIC
GROUP, WE SEE THAT ON THE LEFT
YOU SEE THE 20-MINUTE DRIVE AND
RIGHT YOU SEE 60-MINUTE DRIVE
AND 60-MINUTE VIEW, ALMOST
EVERYBODY HAS PRETTY GOOD ACCESS
TO EITHER IN-PATIENT OR
OUT-PATIENT FACILITY AND BY THAT
THEY CAN GET THERE WITHIN A 60
MINUTE DRIVE AND LESS THE CASE
FOR A 20 MINUTE DRIVE AND SEE
HERE IN-PATIENT FACILITY ACCESS
IS LOWER FOR PEOPLE IN SAY THE
SOUTH FOR WHITE INDIVIDUALS AND
OVERALL IT IS ONLY A LITTLE BIT
UNDER 60%.
NEXT SLIDE.
>> IF WE BREAK IT APART BY
IN-PATIENT VERSUS OUT-PATIENT
FACILITIES, YOU SEE HERE THAT IN
RURAL AREAS THERE IS AN ACCESS
GAP PARTICULARLY WITH RESPECT TO
IN-PATIENT FACILITIES AND
LIGHT-BLUE BARS SHOW URBAN AREAS
AND DARK BLUE SHOW RURAL AREAS
AND LOOKING AT SHARE OF
INDIVIDUALS WITH MENTAL HEALTH
FACILITY WITHIN A 60-MINUTE
DRIVE AND NEARLY EVERYBODY IN A
RURAL AREA CAN GET TO IN-PATIENT
FACILITY AND 60% OF THOSE IN
RURAL AREAS GET TO IN-PATIENT
FACILITY.
NEXT SLIDE.
COEFFICIENTS YOU SEE HERE ARE AS
I SAID ASSOCIATIONS THAT ARE
ELASTICITY AND SHOW EFFECT OF 1%
INCREASE IN COUNTY'S DEPRESSION
RATE AND OVERALL DEPRESSION RATE
AND SEVERE ASSESSED DEPRESSION
RATE BY -- IN THE COUNTY. WE
ARE DOING IT FOR DIFFERENT SIZED
AREAS.
MAIN THING TO FOCUS ON HERE IS
WHETHER CO EFFICIENT IS POSITIVE
OR NEGATIVE AND WHILE AGGREGATE
OVERALL DEPRESSION IS RELATED TO
HAVING MORE FACILITIES, IT IS
NOT THE CASE FOR SEVERE
DEPRESSION AND PARTICULARLY IN
RURAL AREAS SEEING STATISTICALLY
SIGNIFICANT NEGATIVE ELASTICITY
AND FEWER FACILITIES IN RURAL
AREAS GREATER NEED FOR TREATMENT
FOR SEVERE DEPRESSION.
NEXT SLIDE.
I WILL CONCLUDE. WE SHOW IN THE
WORK SO FAR LARGE SHARE OF US IS
WITHIN DRIVING DISTANCE TO
MENTAL HEALTH FACILITY AND
ACCESS IS -- IT IS LACKING FOR
BOTH FOR PEOPLE IN RURAL AREAS
AND WE DO SEE THAT, AGAIN,
FACILITY LOCATIONS POSSIBLY
CORRELATED WITH POPULATION NEED
EXCEPT IN RURAL AREAS AND
PARTICULARLY FOR PEOPLE WITH
SEVERE DEPRESSION. THANK YOU.
>> THANK YOU SO MUCH.
WE WILL NOW MOVE INTO OUR
QUESTION AND ANSWER PERIOD. WE
WILL TRY TO GO A LITTLE BIT INTO
THE BREAK UNTIL ABOUT 5 AFTER.
IF YOU CAN KEEP YOUR ANSWERS
FAIRLY SHORT TO GET TO A COUPLE
OF THESE I WOULD APPRECIATE IT.
DR. HORVITZ LENNON WAS
ENROLLMENT IN NEW YORK STATE
VOLUNTARY PAYMENT MODEL
VOLUNTEER OR SPECIFIC INCLUSION
CRITERIA AND TALKING ABOUT HOW
MANY PROVIDERS ENROLLED?
>> SURE. SO THE POLICY WAS
ACTUALLY VOLUNTARY. IT WAS NOT
MANDATORY.
THE -- THE INCLUSION -- THERE
WAS NO SPECIFIC INCLUSION
CRITERIA AND STATE WAS IN BROAD
ADOPTION OF POLICY AND THAT
PERIOD AND 5 YEAR WAIVER GOING
BETWEEN 2015 AND 2020.
WHAT WE KNOW IS THAT FOR THE
SPECIFIC POPULATION OF PEOPLE
WITH SERIOUS MENTAL ILLNESS,
FIRST YEAR, MOREOVER, HALF OF
THE BENEFICIARIES WITH SERIOUS
MENTAL ILLNESS WERE COVERED IN
VALUE BASED CONTRACTS 56%.
ALREADY IN 2018, SECOND YEAR,
PROPORTION WENT UP TO 75%.
WHAT WE KNOW IS THAT IN THE
SUBSEQUENT YEARS IT IS ACTUALLY
APPROACHING 100%.
>> GREAT. THANK YOU. DR. BAO,
IN GENERAL, HOW DO SYSTEMS AND
CLINICS UNDERSTAND PAYMENT
APPROACHES? WHAT IS OPTIMAL FOR
THEM? OTHER THAN CONSULTING
WITH EXCELLENT, EXCELLENT
EXPERTS LIKE YOURSELF ARE THERE
OTHER WAYS OR FOLKS THEY CAN
CONSULT WITH THAT DETERMINE WHAT
IS OPTIMAL?
>> GREAT QUESTION. SHORT ANSWER
IS IN [INDISCERNIBLE] THERE IS A
HUGE VARIATION ACROSS 100 PLUS
OTPS IN TERMS OF RESOURCES AND
CAPACITIES AND THERE ARE FOR
PROFIT ORGANIZATIONS THAT HAVE
MULTIPLE CLINICS WHO HIRE
PRIVATE CONSULTANTS AND BILLING
CONSULTANTS TO WORK WITH THEM,
YOU KNOW, ALL THE TIME. THEY
ARE ON TOP OF PAYMENT CHANGES
AND HOW TO LEVERAGE PAYMENT
INNOVATIONS.
THERE ARE NON-PROFIT AND NEWLY
ESTABLISHED OTPS IN RESOURCE
POOR AREAS THAT SERVE AS
CRITICAL TREATMENT RESOURCES FOR
THE AREA. THEY SIMPLY DON'T
HAVE BANDWIDTH AND DON'T HAVE
DESIGNATED FINANCIAL STAFF TO
CONDUCT BILLING.
SO THERE IS A HUGE VARIATION AND
GENERAL LESSON WE DRAW FROM THIS
IS WHEN STATE ROLLS
OUTINOVATIONS IT IS NOT JUST
BILLING GUIDANCE TYPICALLY. WOW
SEE A DOCUMENT OF BILLING
GUIDANCE THAT SOMETIMES IS NOT
GOING TO BE SUFFICIENT.
ESPECIALLY FOR THE LESS
ADVANTAGED ORGANIZERS.
>> THANK YOU. DR. SEVIN I SEE
USAGE LATE INCREASED AND WHY DO
YOU THINK IT LED TO IMMEDIATE
DECREASE IN PSYCHOTHERAPIUTE
WILLIZIZATION AMONG FOLKS WITH
PMAD?
>> GOOD QUESTION THAT WE
WONDERED ABOUT THIS. ONE
HYPOTHESIS IS THAT THERE MIGHT
NOT HAVE BEEN ENOUGH MENTAL
HEALTH CLINICIANS TO MEET THE
NEW DEMAND AND SOMETHING TO
EXPLORE FURTHER, A LOWER
STANDARD COSTS AND REIMBURSEMENT
TO PROVIDERS MIGHT HAVE
PREVENTED MORE PROVIDERS FROM
SEEKING TO COME INTO PROVIDE
CARE AND SO, AGAIN, THAT IS ONE
REASON AS WELL AS THE LACK OF
TELEMENTAL HEALTH AT THE TIME.
THANK YOU.
>> THANK YOU.
>> DR. MAESTAS, COULD YOU BE
SPECIFIC ABOUT DEFINITION OF
MENTAL HEALTH FACILITY THAT ARE
LOCATED IN NONSPECIAL HEALTH
FACILITIES AND DID THE STUDY
ACCOUNT FOR THAT?
>> YEAH. IT IS A VERY BROAD
LIST. YOU KNOW, AT THIS POINT
WHAT WE ARE ABLE TO TAKE ACCOUNT
OF IS WHAT LEVEL OF NEED WOULD
BE FOR GIVEN PAISHIENT AND
WHETHER THEY COULD ACCESS
FACILITY THAT WOULD MATCH LEVEL
OF NEED AND LIST DOESN'T INCLUDE
COMMUNITY MENTAL HEALTH CENTERS
AS I SAID AND HEALTH FACILITIES
OUT PATIENT FACILITIES
RESIDENTIAL TREATMENT FACILITIES
PARTIAL HEALTH PHYSICIAN AND DAY
TREATMENTS AND PSYCHIATRIC
HOSPITAL AND SEPARATE IN PATIENT
PSYCHIATRIC UNITS OF GENERAL OR
STATE HOSPITAL AND DON'T KNOW IF
IT ENCOMPASSES THE QUESTIONER'S
SPECIFIC QUESTION ABOUT
NONSPECIALTY FACILITIES BUT WE
WERE NOT COUNTER FOR EXAMPLE A
GENERAL EMERGENCY DEPARTMENT
WHERE SOMEBODY MIGHT BE BOARDED.
>> THANK YOU. DR. MCCONNELL, I
WILL CONCLUDE WITH YOU.
HOW DO YOU THINK ACCESS TO CARE
CAN IMPROVED WITHIN CONSTRAINED
PROVIDER LANDSCAPES AND DELIVERY
SYSTEMS? WHAT DO YOU SEE AS
NEXT STEP AFTER YOUR WORK THAT
SHOWED THAT ONE OPTION DIDN'T
REALLY DO WHAT WE HOPED IT WOULD
DO AND WHAT DO YOU SEE AS NEXT
STEPS AND HOW CAN ACCESS BE
IMPROVED WITHIN CONSTRAINTS?
>> I THINK THAT YOU KNOW THERE
IS DEBATE ABOUT WHETHER THE
FEDERALIST NATURE OF MEDICAID IS
A STRENGTH OR WEAKNESS AND TO
SOME EXTENT STATE'S FLEXIBILITY
TO OTHERS DOESN'T PROVIDE
STANDARDIZATION COMING FROM
FEDERAL LEVEL AND MORE
INTERESTING PLACE FOR LEVERS TO
BE APPLIED IS THAT MCO
PROCUREMENT STAGE AND MOST KNOW
MEDICAID IS INCREASINGLY
COVERING PEOPLE THROUGH MCOS AND
SO STATES HAVE SOME POWER THERE
TO REQUIRE MCOS TO -- TO PROVIDE
NETWORKS IN CERTAIN WAYS AND FOR
EXAMPLE REQUIRE ALL SCHOOL BASED
MENTAL HEALTH CARE TO BE AND
NETWORK AND THOSE THINGS AND
EXPAND PROVIDER SCOPE TO USE
MORE PEER SUPPORT OR COMMUNITY
HEALTH WORKERS OR OTHER TYPES OF
THINGS MAKING IT EASIER FOR
PEOPLE TO PAY FOR THOSE.
SO I THINK THAT YOU KNOW
EXPANDING OUR OPTIONS THERE AND
THINKING ABOUT REQUIRING MCOS TO
HAVE SOME OF THE NETWORK MAKING
IT EASIER FOR PEOPLE TO GET PAID
BEYOND TRADITIONAL PROVIDER
TYPES IS ONE WAY TO RESPOND TO
NEED FOR ACCESS.
>> THANK YOU. DOES ANYBODY ELSE
WA PT TO CONTRIBUTE TO THAT
QUESTION?
>> YEAH. IF I MAY JUMP, MARY.
I WOULD JUST ADD THAT IT IS
CRITICAL THAT PEOPLE WITH
SERIOUS MENTAL ILLNESS AND
SUBSTANCE USE DISORDERS REMAIN
COVERED BY MEDICAID WITH
MEDICAID BEING AN IMPORTANT
PAYER FOR THIS POPULATION.
COVERAGE HAVING LITTLE FRICTION
FOR THESE INDIVIDUALS WHO MAY
HAVE DIFFICULTY NEGOTIATING
COMPLEX APPLICATION PROCESSES AS
WELL AS ENSURING THAT PROVIDER
NETWORKS ARE EXTENSIVE AND REAL.
AND THAT MEDICAID PROVIDERS ARE
WELL-PAID SO THAT IT MAKES IT
POSSIBLE FOR THEM TO PROVIDERS
TO COME INTO THE MEDICAID SPACE.
>> THANK SO YOU MUCH. I THINK
THAT THIS WILL CONCLUDE OUR
PANEL AND THANKS SO MUCH TO OUR
PRESENTERS.
HELLO EVERYONE, WELCOME BACK
FROM BREAK.
A QUICK REMINDER IF YOU CAN'T
ACCESS THE Q&A POD E-MAIL YOUR
QUESTIONS TO CLARE BEARD WITH
THE SUBJECT LINE WORKSHOP
QUESTION.
I'M EXCITED TO ANNOUNCE OUR NEXT
SESSION ON SPECIAL POPULATIONS
AND AT THIS TIME I'M THRILLED TO
HAND IT OVER TO OUR FACILITATOR.
SHANNON, TAKE IT AWAY.
>> I HOPE YOUR ENJOYING THE
PRESENTATION AND I'M SHANNON
BIELLO AT AN ORGANIZATION CALLED
SHATTER PROOF AND LOOK AT
QUALITY OF CARE FOR SUBSTANCE
USE DISORDER SITES AND OFFERING
INFORMATION PUBLICALLY THROUGH
TREATMENT ATLAS.
I'M JOINED BY A GROUP OF
ESTEEMED PANELIST I'LL INTRODUCE
TO YOU BUT FIRST I WANT TO
EMPHASIZE HAVING A CLEAR
UNDERSTANDING OF THE NEEDS OF
SPECIAL POPULATIONS FOR PLANNING
FOR AND DELIVERING MENTAL HEALTH
AND SUBSTANCE USE DISORDER
TREATMENT IS IMPORTANT AS WE
WORK TO IMPROVE PATIENT
OUTCOMES.
ALL OF US HAVE A STRONG
UNDERSTANDING OF THAT.
I'VE CERTAINLY SEEN THIS IN MY
WORK AS WE OFFER SERVICES FOR
SPECIAL POPULATIONS AND PEOPLE
CAN MAKE INFORMED DECISIONS
ABOUT CARE AND EXPLORE TREATMENT
NEEDS FOR SPECIAL POPULATIONS
USING A HEALTH ECONOMIC LENS.
AGAIN, AS MENTIONED I'M THRILLED
TO WELCOME MY ESTEEMED PANELIST
AND INTRODUCE THEM IN ORDER OF
PRESENTATION AND DIVE INTO THEIR
WORK.
FIRST WE HAVE DR. SEAN MURPHY
PROFESSOR AT THE DEPARTMENT OF
POPULATION HEALTH SCIENCES AT
WEILL CORNELL MEDICINE AND
TRAINED HEALTH ECONOMIST WHO
UNDERSTANDS CHRONIC CONDITION
MANAGEMENT AND SUBSTANCE USE
DISORDERS AND DETERMINATES OF
HUMAN ACCESS OUTCOMES AND
ADVERSE AFFECTS.
FOLLOWING WE HAVE DR. ZHU AN
INTERNIST AND GERIATRICS WHOSE
RESEARCH FOCUSES ON RESEARCH
ACCESS AND QUALITY AND FINALLY A
PRESENTATION FROM DR. CATHERINE
MACLEAN AND ASSOCIATE EDITOR
FOCUSSING ON SUBSTANCE USE AND
PUBLIC POLICY.
I THINK WE'LL HAVE EXCELLENT
WORK TO LOOK FORWARD TO THESE
PRESENTATIONS.
AFTER THE PRESENTATION CONCLUDES
WE'LL USE REMAINING TIME FOR
QUESTIONS.
SUBMIT ANY QUESTIONS THROUGH THE
Q&A FEATURE AS MENTIONED AT THE
BEGINNING OF THE PRESENTATION.
OF COURSE FEEL FREE TO REACH OUT
IF YOU HAVE ISSUES WITH THAT AND
I'LL TURN IT OVER TO DR. MURPHY.
THANK YOU.
>> HELLO, EVERYONE.
IT'S A PRIVILEGE TO BE HERE.
I'M GOING TO TALK TODAY ABOUT
WHAT'S GOING ON WITH THE J COIN
AT WORK PRIMARILY AND THE
ECONOMIC ASPECT AROUND THAT AND
SPECIAL CONSIDERATIONS FOR
INDIVIDUALS ENGAGED IN THE
CRIMINAL LEGAL SYSTEM.
THESE ARE THE DIFFERENT STUDIES
WE WERE ENGAGED WITH DIRECTLY AS
WELL AS OTHER STUDIES THAT
HELPED INFORM THE WORK.
>> YOU MAY WANT TO TURN OFF YOUR
CAMERA.
WE'RE HAVING A LITTLE BIT OF A
LAG WITH YOUR FEED.
>> YEAH, SORRY.
MY NETWORK MAY NOT BE THE BEST.
WHAT I WANT TO HIGHLIGHT ARE KEY
GAPS IN THE AND WHAT J COIN WILL
DO TO ADDRESS THIS.
WE HAVE HIGH RATES OF OPIOID USE
DISORDER AMONG CRIMINAL
INDIVIDUALS AND FEW STILL
RECEIVE EVIDENCE-BASED CARE.
WE ALSO KNOW THAT CRIMINAL LEGAL
HEALTH CARE BUDGETS ARE POOR AND
THERE'S NOT A LOT OF FLEXIBILITY
SO JAILS AND PRISONS ARE ALREADY
ON MODEST FIXED ANNUAL BUDGETS
WITHOUT THE ABILITY TO HAVE
SEPARATE FUNDING SAY THROUGH
INSURANCE WITH THE EXCEPTION OF
A FEW STATES WITH WAIVERS FOR
THAT.
AND OF COURSE WE HAVE
EVALUATIONS.
THE POINT IS TO INFORM DECISION
MAKERS AND FOCUS ON EFFICIENCY
BECAUSE THAT'S HOW WE'LL BE ABLE
TO REACH THE LARGEST NUMBER OF
PEOPLE IN NEED.
AND THAT REQUIRES COST AND
EFFECTIVENESS OF ALTERNATIVE
STRATEGIES.
SO, WHEN IT COMES TO EVIDENCE
REGARDING THE RELATIVE ECONOMIC
VALUE OF DIFFERENT O.U.D.
POPULATIONS AND ACROSS THE
SETTINGS, WHEN IT COMES DOWN TO
IT WE DON'T KNOW A WHOLE LOT.
THERE'S A GREAT DEAL OF
VARIATION WITH THE STUDY DESIGNS
AS WELL AS OTHER ASPECT OF WHEN
WE THINK ABOUT THE PERSPECTIVES,
HOW WE'RE MEASURING RESOURCES
AND HOW WE'RE MEASURING
EFFECTIVENESS.
THEY'RE ALL COMPLICATIONS THAT
ARE FACED AS WELL AS
UNDERSTANDING.
EVEN WHEN WE HAVE EVIDENCE-BASED
TREATMENT WHEN IT COMES DOWN TO
THERE'S A NEED FOR UNDERSTANDING
WHAT IT WILL TAKE TO GET IT
START AND GOING IN SETTINGS LIKE
JAIL OR PRISON.
GATE COIN IS GOING TO ADDRESS A
GREAT DEAL OF THESE LIMITATIONS
AND GREATLY EXPAND WHAT WE KNOW
ESPECIALLY WITH REGARD TO
ECONOMIC INFORMATION IN THIS
AREA.
IT'S A LARGE PROJECT.
WE HAVE 12 RESEARCH HUBS AND TWO
LARGE RESOURCE CENTERS AND
COVERS MULTIPLE KEY TOUCH POINTS
FOR INDIVIDUALS INVOLVED IN THE
CRIMINAL LEGAL SYSTEM AND JAILS
AND PRISONS, COMMUNITY
SUPERVISION, DRUG COURTS AND
I'LL TALK MORE ABOUT THAT IN A
SECOND AND A RANGE OF
INTERVENTIONS INCLUDING THERAPY,
PEER SUPPORT INTERVENTIONS, CASE
MANAGEMENT, NOVEL COURT MODELS
AND MY FAVORITE, JCOIN OR NIDA
HAD THE FORESIGHT TO EMPHASIZE
RIGOROUS ECONOMIC CONDITIONS
ACROSS THE DIFFERENT STUDIES.
BECAUSE EVERY SITE WAS
ENCOURAGED TO HAVE AN ECONOMIC
EVALUATION WE ESTABLISHED AN
INFORMAL WHAT WE CALL A HEALTH
ECONOMIC ANALYTIC TEAM AND
WORKED TOGETHER ACROSS THE
DIFFERENT HUBS TO MAKE SURE WE
HAD COMMON ECONOMIC MEASURES
INCLUDING WITH REGARD TO
MEASURING INTERVENTION COST AND
HEALTH CARE UTILIZATION AND
CRIMINAL ACTIVITY AND OTHER
SOCIAL COSTS.
WE DID THIS ACROSS THE VARIOUS
TOUCH POINTS.
NOT EVERYTHING IS GOING TO BE
RELEVANT IN EVERY SETTING SO
THERE WAS CONSIDERATION ACROSS
ALL THE SETTINGS YOU SEE HERE.
HAD TO HAVE COMPARISONS
INCLUDING THE NEW XR
FORMULATIONS AND WHEN IT COMES
TO THESE SETTINGS THERE'S A
GREAT DEAL OF UNCERTAINTY AND
POTENTIAL PRIZE.
AGAIN, THOSE ARE VERY EXPENSIVE
SO WE NEED TO REALLY LOOK AT
THOSE ALTERNATIVES CAREFULLY.
AND IN THE SERVICE MODEL
EXAMPLES AND NAVIGATION AND
SUPPORT AND TELEHEALTH, CASE
MANAGE
MANAGEMENT, TRANSITIONS CLINIC
AND SYSTEMS LEVELS AS PEOPLE
EXIT THE COMMUNITY HOW TO
SUPPORT THEM.
SO, THE SPECIAL CONSIDERATIONS
WHEN IT COMES TO FOCUSSING ON
ECONOMIC EVALUATIONS AND
DIFFERENT SETTINGS, AS WE KNOW
WITH REGARD TO THE SECOND PANEL
AND COST EFFECTIVENESS THE TWO
PERSPECTIVES ARE THE HEALTH CARE
SECTOR AND SOCIETAL PERSPECTIVE
AND WHEN IT COMES TO MAKING SURE
WE'RE INFORMING OUR DECISION
MAKERS.
AND OF COURSE WHEN IT COMES TO
THESE POPULATIONS, ONE OF OUR
PRIMARY DECISION MAKERS ARE SAY
POLICY MAKERS, TAXPAYERS.
SO NEXT SLIDE.
AS YOU CAN SEE, WHEN IT CAME
TIME TO DESIGN THE ECONOMIC
EVALUATIONS, THIS WAS SOMETHING
WE PUT A GREAT DEAL OF THOUGHT
INTO WHAT DO WE NEED TO COLLECT
AND MEASURE AND VALUE IT SO IT
SPEAKS DIRECTLY TO THE POLICY
MAKERS.
SO THAT WAS A MAJOR
CONSIDERATION.
ALSO, OTHER CHALLENGES THAT WE
WE FACE WITH REGARD TO DATA
COLLECTION.
WE HAVE FRAGMENTED SYSTEMS,
HEALTH CARE DATA ARE RARELY
LINKED WITH CRIMINAL LEGAL DATA
AND HAVE INSTRUMENTS SUCH AS
SERVICES AND CRIMINAL ACTIVITY
FORMS WITH ADMINISTRATIVE
RECORDS WHENEVER THEY WERE
AVAILABLE.
ONE OF THE THINGS WE SPENT A LOT
OF TIME ON IS UNIQUE CHALLENGES
AND WHEN WE TALK ABOUT SOURCES
IN SUSTAINED IN A PROGRAM WITHIN
AN A FACILITY SOME THINGS THAT
COME UP CONSISTENTLY ARE STIGMA
OF COURSE.
THERE'S CONSIDERATION FOR STAFF
TRAINING AND STIGMA REDUCTION.
DIVERSION OF PREVENTION MEASURES
IN CARCERAL SETTINGS AND
REGULATORY COMPLIANCE.
SO DECISIONS REGARDING WHICH
WE'LL OFFER AND HOW TO
ADMINISTER THEM ARE BY LOCAL
LAWS AND BUDGET CONSTRAINTS AS
WELL.
SOME DIFFERENT MODELS WE
IDENTIFIED WITH REGARD TO
SUPPORTING INDIVIDUALS WITH OUD
AND OFF SIGHT MEDICATION,
ADMINISTRATION, ON SITE
ADMINISTRATION BY AN EXTERNAL
PROVIDER, NALTREXONE AND
LICENSED CORRECTIONAL
PROEFRLPROEFRLD
ERS -- PROVIDERS PROVIDING
BUPRENORPHINE ON SITE AND DO
THEY BRING THE MEDICATION IN?
DO THEY BECOME A LICENSED HEALTH
CARE FACILITY?
THERE'S DIFFERENT OPTIONS AND
THEY CAN BE COMBINED AS WELL.
WHEN IT COMES TO QUITE A FEW
DIFFERENT PACKAGES THAT CAN BE
PUTTING TOGETHER WITH THESE IN
CORRECTIONAL SETTINGS.
SO ONE OF THE THINGS WE DID
EARLY ON AND THIS WAS INFORMED
BY OUR WORK WITH JCOIN AND OUR
WORK WITH JAILS AND PRISONS
OUTSIDE OF JCOIN BUT WAS PUTTING
TOGETHER A BUDGET IMPACT TOOL TO
HELP INFORM SITES THAT ARE
GETTING READY TO IMPLEMENT OUD
WHETHER BY CHOICE OR STATE LAW.
THIS IS A SCREEN SHOT OF THE
DASHBOARD AS WELL AS AN EXAMPLE
OF OTHER SHEETS AND THE
MANUSCRIPT IS A USER MANUAL, IF
YOU WILL, IN OPEN ACCESS AND ON
THE WEBSITE.
IT'S EASY TO FIND AND IF YOU GO
TO THE JCOIN WEBSITE YOU CAN
DOWNLOAD THE TOOL AND ACCESS IT
FOR FREE SO WE'RE WORKING TO
PROMOTE THAT AND SUPPORT
FACILITIES THAT ARE UNDERTAKING
THIS EN GEFER.
ENDEAVOR.
IN ADDITION, WE THEN USE THAT
TOOL TO DO A COST ANALYSIS WE
OBSERVED WITH THE MASSACHUSETTS
JCOIN INTERVENTION.
YOU CAN SEE THE MOUD INTO
CARCERAL FACILITIES AND WE
IDENTIFIED BASICALLY THREE
DIFFERENT MODELS THAT WERE BEING
USED ACROSS SITES AT LEAST IN A
MASSACHUSETTS MODEL.
A-B WERE SITES THAT CONTRACTED
FOR METHADONE MAINTENANCE.
WE DID BUPRENORPHINE AND
NALTREXONE WITHIN THE FACILITY.
C AND D WERE SITES THAT
CONTRACTED FOR BASICALLY ALL
INDUCTION AND MAINTENANCE WITHIN
THEIR SITES AND THEN SITES D AND
F WERE SITES THAT CHOSE TO
BECOME OTP CERTIFIED.
INTERESTING THING HERE IS WE SEE
A GREAT DEAL OF VARIATION WITH
REGARD TO THE IMPLEMENTATION AND
SUSTAINING COST BUT ONCE WE
ACCOUNT FOR THE DIFFERENT
POPULATIONS AND WE SEE VARIATION
DECREASES A GREAT DEAL AND WE
GET TO A PER PATIENT BASIS WHICH
IS PROMISING REGARDLESS OF WHICH
MODEL YOU CHOOSE TO GO WITH WE
BELIEVE YOU CAN KEEP THE PER
PATIENT COST RELATIVELY LOW AND
STABLE.
SO ALONG SIDE OF THAT WE WERE
ALSO ABLE TO DEVELOP SOME
RECOMMENDATIONS THAT INCLUDE FOR
EXAMPLE DOING ENVIRONMENTAL
SCAN.
DOING RESEARCH.
VISIT OTHER JAILS WHO HAVE
SIMILAR CHARACTERISTICS OF YOURS
AND LEARN FROM WHAT THEY'VE
DONE.
KNOW YOUR COMMUNITY AND BUILD
RELATIONSHIPS WITH THE OPIOID
TREATMENT PROVIDERS AND OTHER
CLINICS.
SO WHEN IT COMES TIME TO RELEASE
AND LINK INDIVIDUALS TO CARE,
THAT'S A MUCH MORE
STRAIGHTFORWARD PROCESS.
UNDERSTAND WHAT VENDORS ARE
OFFERING AND WHETHER IT'S AN
OPTION YOU SHOULD CONSIDER.
CONSIDER THE TRADE-OFFS AND
MAYBE YOU WANT TO COMBINE
CONSIDERATION THE OPTIONS AND
TRAINING FOR STAFF.
AND THEN OF COURSE THINK ABOUT
SPACE CONSIDERATIONS.
DO YOU HAVE THE SPACE, FOR
EXAMPLE, DO YOU HAVE SPACE NOT
BEING USED, CAN YOU BUILD THE
DISPENSARIES, IS THAT AN OPTION?
>> WE'RE AT TIME.
APOLOGIES.
>> THANK YOU.
THAT'S PRETTY MUCH THE END
ANYWAY.
THANK YOU.
>> THANK YOU, DR. MURPHY.
NEXT WE WILL HAVE A PRESENTATION
BY DR. JANE ZHU.
>> GOOD MORNING THANK YOU F.
I'M GRATEFUL TO NIMHD FOR FUND
THIG ING THE WORK AND OUR TEAM
SHOWN HERE.
SO, MEDICAID HAS BEEN TALKED
ABOUT BEFORE AS THE LARGEST PAIR
FOR MENTAL HEALTH SERVICES IN
THE U.S.
ABOUT 2 IN 5 ENROLLEES HAVE A
DIAGNOSED MENTAL HEALTH OR
SUBSTANCE USE CONDITION AND
THEY'RE MORE LIKELY TO HAVE
SERIOUS MENTAL ILLNESS BUT HALF
OF THOSE INDIVIDUALS REPORT
UNMET NEEDS.
IN THE SETTING MANAGED CARE
ORGANIZATIONS OR MCOs HAVE HAD A
GROWING INFLUENCE IN ACCESS TO
CARE ON HOW CARE'S DELIVERED AND
87% OF ENROLLEES ARE NOW COVERED
WITH STATE VARIATION BUT THEY'RE
STATE CONTRACTED RISK VARYING
HEALTH PLANS WITH A CAPPED RATE
TO MANAGE AND DELIVER CARE.
MCOs CONTROL SEVERAL LEVERS THAT
CAN SHAPE ACCESS TO CARE.
THEY INTERSECT WITH STATE
POLICIES AND PROCUREMENT
PROCESSES AS WELL AS PLANNED
STRUCTU
STRUCTURES CRITICALLY DESIGN AND
MAINTAIN NETWORKS AND THESE ARE
THE CLINICIANS AND FACILITIES
ENROLLEES CAN ACCESS PLANS
CONTRACT WITH FOR CARE.
SELECTIVE CONTRACTING CAN
PROMOTE EFFICIENCY OR QUALITY
BUT IF YOU HAVE OVERLY NARROW
NETWORKS YOU RISK REDUCING
ACCESS AND POTENTIALLY WORSENING
OUTCOMES.
IN PRIOR WORK WE'VE SHOWN MENTAL
HEALTH PROVIDER NETWORKS TEND TO
BE NARROW ACROSS MARKETS.
WHEN WE LOOK FOR EXAMPLE AT
NETWORK BREADTH ACROSS MEDICARE
ADVANTAGE PLAN HALF OF ALL
PSYCHIATRIST NETWORKS INCLUDE
FEWER THAN 25% OF AVAILABLE
PSYCHIATRIST MARKET AND ACROSS
STUDIES NETWORKS ARE NARROWER
THAN FOR PRIMARY CARE OR OTHER
SPECIALTIES LIKELY DUE TO A
COMBINATION OF MCO STRATEGIES
AND WORKFORCE SUPPLY
CONSTRAINTS.
QUE KNOW IN OREGON OVER HALF
LISTED HAD LITTLE CLAIMS
ACTIVITIES OR NONE AT ALL AND
WERE GHOST NETWORKS OF PROVIDERS
INACTIVE.
SO PROVIDER NETWORKS ARE A KEY
LEVER THROUGH WHICH MCOs ACCESS
CARE AND LITTLE IS KNOWN HOW
THEY'RE STRUCTURED OR IN
PRACTICE AND IS PROBLEMATIC
WHERE IN MEDICAID OUT OF NETWORK
ARE LIMITED FOR ROUTINE CARE.
OUR WORK IS PART OF A LARGER
GRANT TO ACCESS MEDICARE CLAIM
DATA TO LOOK AT AC SIS SAYS AND
OUTCOMES AND WE HAVE FOUR AIMS.
EXITS OUT OF MARKETS TO STUDY
UNVOLUNTARY NETWORK DISRUPTIONS
AND I'LL FOCUS TO LOOK AT
FOUNDATIONAL DESCRIPTIVE WORK
WE'VE DONE IN SUPPORT OF THESE
AIMS.
WE USED SOURCES FROM THE TAFT
FILES, 2016 ON AS MANY KNOW, THE
TAFT FILES ARE COMPREHENSIVE
ENROLLEE LEVEL CLAIMS DATA
RELATED TO SERVICE UTILIZATION
FOR ALL 50 STATES AND THE
DISTRICT OF COLUMBIA.
PART OF THE FILES INCLUDING APL
OR MANAGED PLAN FILES CLAIMING
INFORMATION AND PROVIDER
INFORMATION AND SUPPLEMENT THE
DATA SOURCES WITH ADDITIONAL
DATA ON PLAN QUALITY.
BEYOND NETWORK WE MEASURE
NETWORKS INCLUDING A PROVIDER TO
ENROLLEE AND LOOK AT MEASURE
PROVIDER CHURN AND MEASURE OF
PANEL SIZE TO UNDERSTAND
PATTERNS OF ENGAGEMENT WITHIN
THE MCO NETWORKS.
WE'VE CONNECTED A FEW KEY
MILESTONES SO FAR INCLUDING THE
DEVELOPMENT OF AN MCO CROSSWALK.
THIS IS A HERCULEAN EFFORT TO
SIMPLIFY THE TAFT FILES AGAINST
CMS ENROLLMENT AND MANUAL
CHECKING THAT IS LED BY THE
CENTER FOR HEALTH SYSTEMS
EFFECTIVENESS AND IS A
CROSS-CENTER EFFORT.
WE'VE ALSO BUILT ENROLLEE AND
PROVIDER COHORTS AND LINKED THEM
TO MCOs AT THE COUNTY LEVEL AND
PERFORMED DESCRIPTIVE ANALYSIS
ON NETWORK COMPOSITION AND
TURNOVER.
LET'S LOOK AT SELECTED RESULTS
NOW.
USING TAF APR AND CLAIMS DATA WE
ESTIMATED ENROLLMENT.
THESE RANGE FROM 68% TO 89% AND
THE LOWEST AMONG PSYCHIATRISTS.
EVEN AMONGST THE ENROLLED
PARTICIPATION IS SHALLOW.
THIS SHOWS PROVIDER ACTIVITY AND
GHOST S AND CORE S SEE MORE THAN
150 UNIQUE ENROLLEES AND THE
PSYCHIATRISTS ARE IN THE MAGENTA
BARS AND AMONG THEM 43% WERE
GHOST PROVIDERS AND 15% WERE
CORE PROVIDERS.
INTERESTINGLY NOT SHOWN HERE BUT
ACROSS ALL SPECIALTIES ONE IN
FIVE GHOST PROVIDERS UP 2019
MOVE TO A DIFFERENT LEVEL OF
PROVIDER PARTICIPATION
SUGGESTING THERE'S SOME FLUIDITY
IN MEDICAID ENGAGEMENT.
PSYCHIATRISTS ALSO DELIVER CARE
TO FAR FEWER ENROLLEES.
IN 2021 THE MEDIAN PSYCHIATRIST
SAW THREE UNIQUE ENROLLEES
COMPARED TO 81 FOR THE MEDIAN
CARDIOLOGIST.
IT HIGHLIGHTS THE FUNDAMENTAL
MISMATCH BETWEEN NETWORK
INCLUSION AND CARE DELIVERY.
AT THE MCL LEVEL WE OBSERVE
PERSISTENT TURN FROM 2020 TO
2021 THERE WERE 670 MCO COUNTY
EXITS AND AFFECTING OVER 2
MILLION ENROLLEES.
PLAN TURNOVER IS FAIRLY MODEST
BUT AFFECTS A SUBSTANTIAL NUMBER
OF ENROLLEES POTENTIALLY
CREATING DISRUPTIONS IN CARE.
FINALLY WE FIND EARLY EVIDENCE
EXISTING MCOs MAY DIFFER FROM
EXISTING MCOs.
THERE'S MORE LIKELY TO SERVE NON
METRO AREAS, TO HAVE LOWER
ENROLLMENT AND HAVE SMALLER MORE
CONCENTRATED MENTAL HEALTH
PROVIDER NETWORKS.
THERE'S LIMITATIONS TO THE
DESCRIPTIVE WORK AND RISK OF
MISCLASSIFICATION OF MCOs AND
PROVIDERS AS WELL AS RELIANCE ON
CLAIMS DATA TO INFER
PARTICIPATION.
BUT IN SUMMARY, MEDICAID
PARTICIPATION AMONG
PSYCHIATRISTS IS GENERALLY
SHALLOW WITH HIGH RATES OF GHOST
PSYCHIATRISTS.
THIS HAS BEEN DEMONSTRATED IN
THE PAST IN A SINGLE STATE OR
SELECT STATE BUT WE SEE IT'S
TRUE ACROSS THE U.S. USING
NATIONAL CLAIMS DATA AND THIS
COULD BE DUE TO FACTORS LIKE
SELECTIVE ENGAGEMENT ON THE PART
OF PHYSICIANS OR GROUP-BASED
CONTRACTING PRACTICES.
MCO CHURN IS MODEST BUT
MEANINGFUL SUPPORTING OUR
PLANNED ANALYTIC APPROACH IN OUR
MAIN AIMS.
WHILE WE DIDN'T COVER THESE WE
SEE NETWORK COMPOSITION AND WE
SEE SOME NETWORKS RELY
RELATIVELY MORE ON MENTAL HEALTH
PRESCRIBERS AND OTHERS MORE ON
THERAPISTS AND COUNSELORS SO
WHAT METRICS CORRELATE WITH USE
AND QUALITY OF CARE ARE
QUESTIONS WE'LL BE EVALUATING IN
SUBSEQUENT AIMS OF THE PROJECT.
FINALLY, THIS WORK UNDER SCORES
THAT STATES AS BROUGHT UP IN
PRIOR TENSIONS HAVE POWERFUL
TOOLS TO INFLUENCE MCOs,
ADEQUACY REQUIREMENTS AND
VARIATION IN PARTICULAR IN
NETWORK STRUCTURE CAN BE
LEVERAGED IN RESEARCH TOE BETTER
TARGET OVERSIGHT AND SHARE
LEARNING AND HOPEFULLY IMPROVE
ACCESS TO QUALITY MENTAL HEALTH
SERVICES IN THE MEDICAID
PROGRAM.
THANKS SO MUCH.
>> THANK YOU, DR. ZHU.
I WANT TO REMIND EVERYONE ALL
OUR PARTICIPANTS IF YOU HAVE
QUESTIONS PLEASE SUBMIT THEM
THROUGH THE Q&A FUNCTIONALITY
BECAUSE IT HELPS US GET THEM KU
QUEUED UP FOR THE QUESTION AND
ANSWER SECTION AND WITH THAT
DR. MACLEAN.
>> THANK YOU TO THE ORGANIZERS.
IT'S BEEN A FANTASTIC WORKSHOP
I'M LEARNING A LOT SO THANK YOU.
WHAT I'LL BE TALKING ABOUT TODAY
IS WHAT I'M CALLING A SLIGHTLY
DIFFERENT TITLE THAN ON THE
WORKSHOP AGENDA SO APOLOGIES BUT
THE CONTENT IS THE SAME.
TIME FOR MENTAL HEALTH CARE,
EVIDENCE FROM PAID SICK LEAVE
MANDATES.
I'D LIKE TO THANK MY AUTHORS.
I'D ALSO LIKE TO ACKNOWLEDGE
NIMHD FOR FUNDING THE WORK.
WE'RE GRATEFUL AND USING
RESTRICTED USE BUREAU OF LABOR
STATISTICS DATA AND OUR FINDINGS
DO NOT REPRESENT THE VIEWS OF
THOSE ENTITIES.
A BIT OF MOTIVATION, I PROBABLY
DON'T HAVE TO SPEND MUCH TIME
GIVEN THE AUDIENCE BUT MENTAL
HEALTH DISORDERS ARE COMMON IN
THE UNITED STATES ONE IN FIVE
INDIVIDUALS EXPERIENCE THE
CONDITIONS.
THERE'S TREATMENTS AVAILABLE FOR
MENTAL HEALTH CARE AND THERE'S
DIFFERENT TYPES OF MENTAL HEALTH
CARE AND THEY'RE VARY THEIR TIME
INTENSITY THE TIME IT TAKES TO
RECEIVE THAT TIME OF CARE.
WE CAN THINK OF A MEDICAID
MANAGEMENT SYSTEM ROUGHLY 15
MINUTES OR THINK ABOUT LONGER
DURATI
DURATIONS OR RESIDENTIAL COSTS
AND THEY MAY BE SALIENT FOR
INDIVIDUALS FACING TROUBLE
SCHEDULING CARE AROUND
INFLEXIBLE WORK SCHEDULES AND
THERE'S HIGHER LEVEL OF UNMET
NEEDS OF CARE IN THE UNITED
STATES.
WE'LL THINK ABOUT THE IMPACT OF
STATE PAID SICK LEAVE MANDATES.
THE UTILITIES DOESN'T HAVE A
PAID SICK LEAVE POLICY.
THE U.S. IS ONE OF FOUR
COUNTRIES THAT LACK A POLICY.
IT'S LARGELY LEFT THE OFFERING
TO THE DISCRETION OF EMPLOYERS
AND 30% SAY THEY LACK PAID SICK
LEAVE AT THEIR EMPLOYMENT.
17 STATES HAVE ADOPTED A PAID
SICK LEAVE PLAN DATE TO REQUIRE
EMPLOYERS TO PROVIDE ONE WEEK OF
PROTECTED TIME A YEAR.
IT CAN BE USED FOR THE
EMPLOYEE'S OWN HEALTH CARE NEEDS
OR DEPENDENTS AND MENTAL HEALTH
CARE IS AN ELIGIBLE SERVICE
UNDER PAID LEAVE MANDATE.
THERE'S A GROWING BODY OF
LITERATURE AND IT'S VERY MUCH A
SUMMARY ON THE IMPACT OF THE
MANDATES.
THERE'S EVIDENCE IT WILL IMPROVE
USE OF MANDATES AND WILL ALLOW
INDIVIDUAL TO USE MORE HEALTH
CARE AND INFLUENZA AND OTHER
TYPES OF PREVENTATIVE CARE.
WE HAVE AN EARLIER STUDY THAT
SHOWS MEDICAID FINANCE FOR
PRESCRIPTION MEDICATIONS FOR
MENTAL HEALTH CONDITIONS ALSO
INCREASED.
WE CAN LOOK AT THESE ACROSS THE
UNITED STATES.
THERE'S CLUSTERING OF CARE AND
WE DON'T SEE A LOT IN THE
SOUTHERN STATES.
HERE WE LOOK AT THE TEMPORAL
VARIATION OF THE PAID SICK LEAVE
MANDATES.
THEY'RE BEING ADAPTED AT
DIFFERENT POINTS FROM DIFFERENT
STATES.
THE DISTRICT OF COLUMBIA WAS THE
EARLIEST ADOPTER IN MAY OF 2008.
OUR RESEARCH QUESTION AND HIGH
BOTH -- HYPOTHESES NEXT AND WE
CONJECTURE MANDATES WILL REDUCE
THE TIME COST FOR REDUCED HEALTH
CARE AND MAY REDUCE THE
FINANCIAL COST BECAUSE THEY'LL
HAVE TO FORGO WAGES TO RECEIVE
WAGES DURING STANDARD WORK TIME
IN 2004 THE MEDIAN DAILY WAGES
WERE $240 AND WE'LL SEE AN
INCREASE IN MENTAL HEALTH CARE
UTILIZATION AND SHIFT FROM LESS
TIME INTENSIVE TO MORE TIME
INTENSIVE TREATMENT AND WE'LL
ALSO LOOK AT THE HEALTH OUTCOMES
AND THINK MENTAL HEALTH OUTCOMES
MAY IMPROVE POST MANDATE.
NU OF THE MAIN DATA SET WILL
HAVE PRESCRIPTION AND CLAIMS AND
WE'LL HAVE A SAMPLE OF PATIENTS
WHO RECEIVE A MENTAL HEALTH OR
SUBSTANCE USE DISORDER DIAGNOSES
BETWEEN 2015 AND 2022.
WE DO LOOK AT A RANGE OF
OUTCOMES TO TRY TO GET AT THE
DIFFERENT TYPE OF CARE WITH TIME
INTENSITIES AND TREATMENT USE
PER STATE, YEAR, MONTH AND WE'RE
FOCUSSING ON PATIENT COUNTS IN
THE ANALYSES PRESENTED TODAY.
THE DESIGN DIFFERENCES WE'LL
HAVE DIFFERENT STATES ADOPTING
POLICIES AT DIFFERENT POINTS.
WE'LL COMPARE OUTCOMES BEFORE
AND AFTER THE INTERVENTION.
THAT'S THE STATE SICK PAID
MANDATE AND COMPARE OUTCOMES IN
THE TREATMENT STATE AND USE
STATES THAT DID NOT ADOPT THE
POLICY AS THE COUNTER FACTUAL.
WE'LL BORROW THE TREND WITH
GREEN REPRESENTING TREATMENT AND
COMPARISON AND THE GAP POST
INTERVENTION FORP THE TREATMENT
STATES AND OF COURSE OUR SETTING
WILL BE MORE COMPLICATED AND
WE'LL USE AN ESTIMATOR GIVEN THE
VARIATION WE HAVE AND LOOK AT
CHARACTERISTICS AND CLUSTER
STANDARD ERRORS BY THE STATE.
I'LL MOVE TO THE FINDINGS.
FIRST I'LL SHOW YOU WHAT I CALL
OUR FIRST STAGE FINDINGS.
WE WANT TO ENSURE WHEN THERE'S
AN ADOPTION EMPLOYERS ARE
GAINING ACCESS AND THE CIRCLES
ARE THE COEFFICIENT ESTIMATES
AND THE WHISKERS ARE THE
CONFIDENCE INTERVALS AND
CONVERTED EVERYTHING TO A
PERCENT CHANGE FOR EASE OF
INTERPRETATION.
WE'RE GOING TO BE USING THE
NATIONAL COMPENSATION SURVEY AND
FOLLOWING THE MANDATE THERE'S A
ROUGHLY 10% INCREASE IN THE
PROBABILITY THE EMPLOYER OFFERS
TO THE EMPLOYEE AND THE
UTILIZATION INCREASED BY 17%
POST MANDATE.
WE TAKE THE EVIDENCE AND
FOLLOWING THE MANDATE, EMPLOYEES
ARE GAINING ACCESS AND USING THE
BENEFIT.
HERE WE'RE LOOKING AT THE ALL
CLAIMS DATABASE AND LOOK AT THE
IMPACT OF THE MANDATES ON ANY
MENTAL HEALTH CARE AND THEN LOOK
AT TYPE OF MENTAL HEALTH CARE
AND FOCUSSING ON LESS AND MORE
TIME INTENSIVE CARE.
WHAT WE OBSERVE IS NO EVIDENCE
THAT THERE'S A CHANGE IN THE
EXTENSIVE MARGIN OF USE.
THAT'S ANY MENTAL HEALTH AND
WHEN WE BREAK IT UP WE SEE A
DECLINE IN PRESCRIPTIONS OF 3.6%
POST MANDATE AND LOOK AT OUT
PATIENT AND IN PATIENT CARE WE
SEE A 22.4 AND 23.5% INCREASE
POST MANDATE AND VIEW IT AS SOME
SUBSTITUTION IN TERMS OF TIMES
INTENSITY.
WE WANT TO TAKE IT FOR
SUBSTITUTION ACROSS THE SETTINGS
OF CARE AND USING DATA WE LOOK
AT SIX MONTHS BLOCKS TO ALLOW
PATIENTS TIME TO RECEIVE MORE
THAN ONE TYPE OF CARE.
AND DIVIDE CARE TO THREE
MUTUALLY EXCLUSIVE CATEGORIES.
PRESCRIPTION MEDICATIONS AND
PRESCRIPTIONS AND NO OUT
PATIENT.
WHEN WE LOOK AT PRESCRIPTION AND
IN OR OUT PATIENT.
FINALLY WE LOOK AT NO
PRESCRIPTIONS AND IN PATIENT OR
OUT PATIENT.
WE CAN THINK ABOUT THESE BEING
LESS AND MORE TIME INTENSIVE.
WHEN WE LOOK AT THE CATEGORIES
WE SEE THE DECLINE IN
PRESCRIPTIONS ONLY.
IT WILL BE A DECLINE OF 7.3%
POST MANDATE AND WE SEE
INCREASES IN THESE ARGUABLY MORE
INTENSIVE TREATMENTS AND THOSE
AFFECTS ARE RELATIVELY SIZABLE
ABOUT 16% TO 21% INCREASE.
FINALLY WE WANT TO PROVIDE
EVIDENCE TO SEE IF THE EVIDENCE
IN TERMS OF THE TYPE OF CARE
WE'RE SEEING.
ARE WE SEEING IMPROVEMENTS IN
MENTAL HEALTH OUTCOMES.
HOW WE'RE GOING TO DO THIS IS
LOOK AT SURVEY DATA FROM
SURVEILLANCE DATA OF ROUGHLY
400,000 INDIVIDUALS EACH YEAR.
WE HAD A MEASURE OF
SELF-PERCEIVED MENTAL HEALTH
PROBLEMS AND REPORTED DAYS OF
POOR MENTAL HEALTH IN THE PAST
30 DAYS AND LOOK AT INDIVIDUALS
BREAKING THEM UP AND LOOK AT
THOSE 18 PLUS THEN BREAK THEM
INTO NON-ELDERLY AND ELDERLY
ADULTS.
WE SEE REDUCTIONS IN THE DAYS IN
POOR MENTAL HEALTH AND IT WILL
RANGE FROM 7.3% AMONGST 18 YEARS
AND OLDER TO 8.3% AMONGST THE
NON-ELDERLY ADULT.
THIS IS WHERE WE SEE INDICATION
OF IMPROVEMENT OF MENTAL HEALTH
AND I'LL SKIP THIS SLIDE BUT
HAPPY TO DISCUSS LATER.
WE WANT TO LOOK AT PROTECTED
TIME AWAY FROM WORK AND YOUR
EMPLOYER ALLOWING YOU TO TAKE
TIME OFF WITHOUT FOREGOING WAGES
AND DO WE SEE CHANGES IN MENTAL
HEALTH SERVICES.
OUR FINDINGS ARE SOMEWHAT
INLINE.
WE EXPECTED TO SEE AN INCREASE
IN OVER ALL MENTAL HEALTH CARE
UTILIZAT
UTILIZATION.
HOWEVER WE STARTED TO CONSIDER
DIFFERENT TYPES OF MENTAL HEALTH
CARE.
EMPHASIZING THOSE THAT DELIVERED
AND SAW PRESCRIPTIONS ONLY AND
INCREASES IN MORE TIME INTENSIVE
MENTAL HEALTH AND SAW SOME
CHANGES IN HEALTH CARE AND TIME
CONSTRAINTS MAY ALLOW PATIENTS
TO SORT INTO THEIR MORE
PREFERRED TYPE OF CARE.
WE ALSO THINK THIS IS EVIDENCE
PATIENTS RESPOND TO PRICE
CHANGES.
IF YOU THINK ABOUT TIME.
I TELL MY STUDENTS, TIME IS
MONEY.
IF YOU THINK OF TIME AS BEING
MONEY THINK OF IT AS A FINANCIAL
COST AS WELL BUT THINK THIS
STUDY CONTRIBUTE TO THE BROADER
LITERATURE ON UNDERSTANDING THE
IMPACTS OF PAID SICK LEAVE
MANDATES ON AMERICAN SOCIETY.
THAT'S ABOUT IT.
THANK YOU VERY MUCH FOR YOUR
TIME.
>> THANK YOU, DR. MACLEAN.
WE'RE GOING TO JUMP OVER TO OUR
PANEL DISCUSSION.
I'LL START WITH A QUESTION ON
DATA.
I THINK WE'VE SEEN SOME RICH
USES OF DATA IN THE VARIOUS
PRESENTATIONS.
AND WE SAW CONSIDERATIONS THAT
HAVE IMPACTED YOUR ABILITY TO
CONDUCT THESE ECONOMIC
EVALUATIONS.
WHY DON'T WE START WITH YOU,
DR. ZHU.
>> SURE.
OUR EVALUATIONS ARE RELIANT ON
TAF DATA NOW SEVERAL YEARS IT'S
BEEN AVAILABLE AND THERE'S
VARIATION AND DATA CAUGHT AS
THOSE WHO USED THE TAF DATA
KNOW.
THE DATA CONSIDERATIONS WITH THE
TAF DATA ARE REALLY FOCUSSED ON
CAN'T GIVE DATA ON WHAT DATA IS
RELIABLE CLEANING THROUGH STATES
AND CLEANING INFORMATION AND
SHARING THAT.
THE MEDICAID DATA LEARNING
NETWORK WITH JOHN McCONNEL AND
EARLIER PRESENTERS LEADING IN
THE WORKSHOP THEY'RE SHARING
THOSE LEARNINGS ACROSS A NUMBER
OF INSTITUTIONS AND THAT'S BEEN
A GREAT RESOURCE.
OVER ALL IN TERMS OF THE
MEDICAID DATA IT'S PROPRIETARY
AND LABOR INTENSIVE AND
EXPENSIVE AND REQUIRES SHARED
LEARNINGS TO MAKE THAT
MEANINGFUL IN A TIMELY MANNER.
>> THANK YOU.
>> THE CLAIMS DATA ARE VERY
USEFUL AND ALSO VERY EXPENSIVE.
THAT MAKES STUDYING THE QUESTION
WITH DATA YOU BELIEVE ARE
SUITABLE AND CAN PROVIDE
INTERESTING PICTURES YOU MAY NOT
BE ABLE TO GATHER FROM
PUBLICALLY AVAILABLE DATA DOES
REQUIRE SHARED LEARNING AND
RESOURCES.
WE'RE GRATEFUL TO NIH.
WE COULD NOT HAVE BEEN ABLE TO
CONDUCT THE RESEARCH WITHOUT THE
FINANCIAL SUPPORT THAT ALLOWS US
TO UTILIZE THE DATA.
I THINK IT'S UNFORTUNATE THAT
THERE ARE THESE COSTS.
WE'RE GRATEFUL FOR THE SUPPORT
AND LEARNING ABOUT THE VARIOUS
NUANCES OF THE CLAIMS DATABASE.
EACH HAS STRENGTHS AND
WEAKNESSES BUT DR. ZHU DID A
GREAT JOB SUMMARIZING THOSE.
>> PERFECT.
DR. MURPHY, ANYTHING YOU WANT TO
ADD WITH DATA CONSIDERATIONS
WITH THESE RESEARCH PROJECTS IN
RELATION TO MENTAL HEALTH AND
SUBSTANCE USE DISORDER?
>> I THINK ONE THING AMONG
CRIMINAL-LEGAL POPULATIONS IS
OUR INABILITY TO UNDERSTAND THE
LONG-TERM IMPACTS IN TERMS OF
THE ONLY DATA AVAILABLE SAY
ADMINISTRATIVE DATA AND NO
MATTER HOW COMPREHENSIVE THAT IS
YOU'RE STILL GET NUANCES WITH
THE INDIVIDUAL TRIALS AND
UNDERSTAND WHO THE INDIVIDUALS
ARE AND WHAT'S GOING ON IN THEIR
LIVES AND SOME OF THE IMPORTANT
CONSIDERATIONS.
I WOULD SAY ACROSS THE JCOIN
NETWORK THERE'S OTHER
CONSIDERATIONS.
>> I WOULD ALSO ADD THAT AS MANY
KNOW THERE'S NOT REELY GREAT
QUALITY MEASURES IN PUBLIC
HEALTH.
AND SO WE'RE JUST TRYING TO GET
AS CLOSE TO THE TRUTH AS
POSSIBLE BUT THE ADMINISTRATIVE
CLAIMS DATA HAS TRADE-OFFS AND
DISADVANTAGES AND SOME THINGS WE
CAN'T GET AT ARE PATIENT
EXPERIENCE.
THOSE DIMENSIONS ARE IMPORTANT
IN MENTAL HEALTH BUT UNDER
STUDIED BECAUSE WE DON'T HAVE
GREAT SOURCES AN THERE'S PROXY
MEASURES OF QUALITY AND THERE'S
STILL CONTENTION AND DEBATE
WITHIN THE FIELD AS TO WHAT BEST
MEASURES QUALITY AND OUTCOMES IN
MENTAL HEALTH AND THAT COULD BE
A WHOLE OTHER PANEL BY ITSELF.
RECOGNIZING THERE ARE
LIMITATIONS ARE IS IMPORTANT.
AS SOMEONE WHO LOVES WORKING
WITH BIG DATA HAS MADE ME
COGNITIVE OF THE ROLE OF DATA
AND INTERVIEWS TO HELP MOTIVATE
QUESTIONS AND GET AT THINGS THAT
LARGE DATA AND ADMINISTRATIVE
CLIMBS OF -- CLAIMS DATA CAN'T
GET TO.
>> THOSE ARE TERRIFIC POINTS AND
WE HAD A QUESTION RELATED TO
DATA ASKING WHAT ARE SOME
PUBLICALLY AVAILABLE DATA SETS.
I KNOW WE MENTIONED CLAIMS HERE
BUT OTHERWISE PEOPLE MAY BE ABLE
TO USE WHEN THINKING ABOUT DOING
THIS TYPE OF RESEARCH WITH
SPECIAL POPULATIONS.
DOES ANYONE WANT TO JUMP IN?
MAYBE DR. MACLEAN.
>> I THINK IT'S A GREAT
QUESTION.
I'M STILL A FAN OF SURVEY DATA.
THEY HAVE THEIR OWN LIMITATIONS
BUT LOOKING AT THE SURVEILLANCE
SURVEY OF 400,000 PER YEAR I
BELIEVE I MENTIONED EARLIER AND
THINKING ABOUT SPECIAL
POPULATIONS THE DATA IS
PUBLICALLY AVAILABLE AND OFFER
THE LARGE SAMPLES AND THERE'S
OTHER DATA SOURCES COLLECTED BY
THE FEDERAL GOVERNMENT AND CAN
BE USEFUL.
THAT'S A NICE PLACE TO START.
>> DR. MURPHY ANYTHING YOU WANT
TO ADD ABOUT PUBLICALLY
AVAILABLE DATA SETS FOR THESE
SPECIAL POPULATIONS?
>> THE ONE THAT COMES TO MIND
WITH PERMISSION OR WITH THAT
CAVEAT OR THE MASSACHUSETTS
Ph.D. AND THOSE DATA SETS WHERE
YOU CAN LOOK AT INDIVIDUALS
ACROSS THE SYSTEM.
THE MORE WE ACCESS THOSE THE
BETTER OFF WE'LL BE IN
ESTIMATING LONG-TERM EFFECTS.
>> DR. ZHU, ANYTHING YOU'D LIKE
TO ADD.
>> WE'VE COVERED IT.
PERFECT.
THANK YOU.
THE QUESTION THAT RELATES TO THE
RICHNESS OF DATA YOU'VE ALL BEEN
ABLE TO PRESENT AND ASKING DO
YOU HAVE STRATEGIES OR BEST
PRACTICES WHEN COMMUNICATING THE
FINDING OR RESULTS TO PEOPLE
OUTSIDE OF FIELDS THAT AREN'T AS
FAMILIAR WITH HEALTH ECONOMICS
WHO DON'T APPLY THAT LENS TO
THEIR WORK IN SPECIAL OPTIONS.
I DON'T KNOW IF YOU HAVE
THOUGHTS ON THAT.
DR. MURPHY, LET'S START WITH
YOU.
>> ONE EXAMPLE WITH COST
EFFECTIVENESS ANALYSIS IS TO
MAKE SURE WE'RE INCLUDING AN
EFFECTIVENESS MEASURE THAT IS
MORE EASY TO UNDERSTAND AND
TRANSLATE AND ALL THOSE THINGS
AND QUALITY ADJUSTED LIFE YEARS.
THEY DON'T NECESSARILY SPEAK AS
CLEARLY TO POLICY MAKERS.
MAKING SURE YOU HAVE SOME OF
THOSE SAY CLINICAL OR OTHER
TYPES OF EFFECTIVENESS MEASURES.
>> DR. ZHU ANYTHING FOR
PARTICULAR FINDINGS TO A
NON-ECONOMIC AUDIENCE.
>> PRESENT COMPANY NOT INCLUDED,
ECONOMISTS ARE NOT KNOWN FOR
BEING OVERLY GREAT AT THIS BUT I
REALLY LIKE PICTURES.
I'M A BIG FAN OF PICTURE.
I THINK A PICTURE CAN CONVEY
1,000 WORDS.
I THINK THINKING ABOUT EXAMPLES
AND METHODS USED TO THINKING
ABOUT TWO STATES NAMING THEM AND
THIS IS WHAT THE ESTIMATOR IS
DOING AT ITS HEART AND
TRANSLATING IT TO THE EXTENT ONE
CAN INTO METRICS THAT ARE EASILY
DIGESTIBLE BE IT THROUGH
PICTURES OR TALKING ABOUT UNIT
MEASURES FOR THE PARTICULAR
AUDIENCE AND TRYING TO
DEEMPHASIZE THE TECHNICAL
ESTIMATE AND FOCUS ON WHAT IS
THE STORY.
I HAD A PREFERS WHO SAID IF YOU
CAN'T DRAW A SIMPLE GRAPH YOU
CAN'T COMMUNICATE AND THAT'S
GOOD FOR THE RESEARCHER
INVOLVED.
>> EXCELLENT POINT.
DR. ZHU, ANYTHING YOU'D LIKE TO
ADD ABOUT COMMUNICATION?
>> INCREASINGLY HAVING AN
INTERDISCIPLINARY TEAM IS
IMPORTANT TO THIS SORT OF WORK
NOT ONLY IN TERMS OF METHODOLOGY
AND SOLIDIFYING THAT BUT IN THE
MOST ROBUST WAY POSSIBLE BUT
MESSAGING AROUND COMMUNICATION
AND PRIORITIES.
I KNOW NIMHD FOR EXAMPLE HAS
BEEN INCREASING LY EMPHASIZING
ADVISORY COMMITTEES OR THOSE IN
THE POLICY WORLD THAT CAN
INTERPRET YOUR RESULTS IN A WAY
THAT'S RELEVANT TO REAL WORLD
SITUATIONS.
IN MY WORK THAT IS SOMETHING
THAT I BUILT IN INCREASING LY I
HAVING PEOPLE IN THE POLICY
WORLD OR PEOPLE WITH LIVED
EXPERIENCE OR OTHER CLINICIANS,
IF I'M STUDYING PSYCHIATRISTS, I
WANT A PSYCHIATRIST ON MY TEAM.
THAT'S IMPORTANT IN TERMS OF HOW
DO YOU INTERPRET AND MESSAGE
SOMETHING FROM YOUR RESULT IS
RELEVANT AND ACCURATE TO THE
PEOPLE IT'S GOING TO AFFECT.
>> TERRIFIC POINTS.
>> OKAY.
I THINK WE HAVE TIME FOR ONE
MORE QUESTION.
WE HAVE SOMEONE ASKING IN THE
RESEARCH WHERE WE'RE FOCUSSED ON
SPECIAL POPULATIONS IN
PARTICULAR SPECIFIC GROUPS AND
INDIVIDUALS, WHAT ARE SOME
IMPORTANT CONSIDERATIONS WHEN
CONDUCTING THE ECONOMIC
EVALUATIONS AND INTERVENTIONS?
WE'LL START WITH YOU,
DR. MURPHY.
>> SIMILAR TO WHAT DR. ZHU WAS
TALKING ABOUT MAKING SURE YOU
HAVE THE INTERDISCIPLINARY TEAM
AND MAKING YOU UNDERSTAND THE
ENVIRONMENT AND SPECIFIC
BARRIERS AND UNCERTAINTIES.
THAT DECISION MAKERS ARE BUMPING
UP AGAINST.
WE NEED TO UNDERSTAND THE
INFORMATION AND WHAT INFORMATION
CAN HELP FACILITATE THAT.
>> DR. MACLEAN.
>> I AGREE TALKING TO PEOPLE AND
HAVING PEOPLE ON YOUR TEAM AND I
LIKE WHAT DR. ZHU SAID HAVE A
TEAM AROUND YOU THAT IS GOING TO
BE ABLE TO UNDERSTAND THE AREAS
OF THE QUESTION YOU MAY NOT HAVE
SPECIFIC EXPERTISE AND EACH
MEMBER WILL KNOW VERY WELL A
SPECIFIC QUESTION AND PEOPLE WHO
HAVE DIFFERENT SKILLS AND LIVED
EXPERIENCES OR THINKING HOW
DECISION MAKERS ACTUALLY MAKE
STIGSES.
BRINGING ALL THOSE FOLKS
TOGETHER I THINK WILL BETTER
ALLOW YOU TO AVOID MISMAPS BY
UNDERSTANDING THE CONSIDERATION
OR NOT CONSIDERING BARRIERS
RELEVANT TO YOUR POPULATION.
>> REALLY GOOD POINTS.
AND DR. ZHU, WE'LL HAVE YOU
ROUND OUT THE QUESTIONS NOW.
ANY FINAL THOUGHTS ABOUT THOSE
IMPORTANT CONSIDERATIONS WHEN
DOING THIS TYPE OF ECONOMIC
ANALYSIS FOR SPECIAL GROUPS?
>> JUST REEMPHASIZING KEEPING
WHO WILL BE AFFECTED BY THESE
RESULTS AND WHO WILL BE AFFECTED
BY THE CENTER OF THE QUESTIONS
YOU'RE ASKING AND HOW YOU'RE
MARKETING AND MESSAGING IS GOING
TO BE THE MOST IMPORTANT.
WE DON'T WANT TO BE COMING IN
WITH THE RIGHT ANSWERS WITHOUT
BEING COGNITIVE AND FAMILIAR
WITH WHAT PEOPLE WANT IN THE
FIELD AND WHAT PATIENTS WANT.
IT'S ULTIMATELY THE ROLE OF
RESEARCHER IS TO MAKE THINGS
EASIER AND BETTER FOR THOSE
PATIENTS AND THOSE CENTERING
THAT IN ALL OF OUR WORK.
>> YEAH.
AND I THINK THAT'S AN ABSOLUTELY
TERRIFIC PLACE TO END.
THE PATIENT CENTERED FOCUS IS A
TESTAMENT TO THE RESEARCH YOU
ALL HAVE CONDUCTED.
WE APPRECIATE YOUR PRESENTATION
AND TERRIFIC WORK.
WE'LL PASS IT ON.
>> THANK YOU, BE SHANNON AND
THANK YOU FOR OUTSTANDING
PRESENTATIONS AND FOR YOUR
EXPERT FACILITATION OF THE
DISCUSSION.
NOW OVER TO OUR NEXT SESSION.
>> THANK YOU.
I SERVE AT THE NATIONAL
INSTITUTE OF MENTAL HEALTH AND
IT IS MY PLEASURE TO INTRODUCE
OUR PANELISTS.
AND CLARE McNUTT FOR THE HEALTH
SYSTEM INTEGRATION AT THE MENTAL
HEALTH POLICY INSTITUTE.
THANK YOU EVERYONE.
OVER TO YOU, KRISTIN AND CLARE.
>> WE'RE HAPPY TO BE HERE TO
TALK ABOUT INTEGRATED MENTAL
HEALTH AND SUBSTANCE USE
TREATMENT.
I'M SURE MANY ON THE CALL TRIED
TO ACCESS MENTAL HEALTH SERVICES
AND RUN INTO MULTIPLE ROAD
BLOCKS IN GETTING AN APPOINTMENT
AND INCREASES IN THE NEED AND
SHORTAGE FOR SUBSTANCE USE
PROVIDERS.
EARLIER WE HEARD AROUND THE
COLLABORATIVE CARE MODELS AND
EARLY INTERVENTION AND
CONVENTION.
THROUGH THIS PANEL WE'LL HAVE
PRESENTATIONS THAT ARE GOING TO
LOOK FORWARD TO A BETTER
UNDERSTANDING OF HEALTH ECONOMIC
BARRIERS.
CHALLENGES AND OPPORTUNITIES FOR
INTEGRATING SUBSTANCE USE AND
MENTAL HEALTH DISORDERS AS WELL
AS WITH PRIMARY CARE.
YOU'LL ALSO HEAR ABOUT THE
ACCESS TO CARE TODAY AS WELL.
I'LL TURN THIS BACK OVER TO
CLARE.
>> AS WE BEGIN THE PANEL, PLEASE
USE THE Q&A BOX TO SHARE
QUESTIONS.
IF YOU'RE NOT ABLE YOU MAY BE
ABLE TO E-MAIL QUESTIONS TO
CLARE AND WE'LL COLLECT THE
QUESTIONS AND RESPOND AFTER ALL
THE PRESENTATIONS ARE FINISHED.
NOW OUR FIRST SPEAKER FROM THE
UNIVERSITY OF UTAH SCHOOL OF
MEDICINE, DR. GORDON.
>> THANK YOU VERY MUCH.
I WANT TO THANK EVERYBODY FOR
ALLOWING ME TO PRESENT TODAY IN
A SHORT 10 MINUTES HERE.
FIRST, THANK YOU TO NIDA AND NIH
FOR FUNDING A LOT OF THIS WORK
AND THE DEPARTMENT OF VETERAN
AFFAIRS.
WE'LL TALK ABOUT HOW WE'RE
CHANGING HOW PEOPLE ARE
ACCESSING SUBSTANCE USE DISORDER
CARE AND PARTICULARLY OPIOID USE
DISORDER CARE AND OUR HEALTH
CARE SYSTEMS IN TRYING TO DERIVE
ADDICTION CARE WITHIN GENERAL
NORMAL HEALTH CARE SETTINGS.
I DO WORK WITH REGARD TO HEALTH
SYSTEM CHANGE AND IMPROVE
ADDITION ACCESS AND I'LL TALK
ABOUT ONE OF OUR PROJECTS WE'RE
DOING WITH REGARDS TO FORCING
THE CHANGE WITHIN DEPARTMENT OF
VETERANS AFFAIRS AND HOW PRIMARY
CARE MAY BE A BETTER COST
EFFECTIVE WAY TO TAKE CARE
PATIENTS WITH ADDITION AND
OPIOID USE DISORDER AND IS AS WE
THINK OF DIFFERENT MODELS OF
CARE THINKING WITH THE ECONOMIC
COST OF ADDITIONAL CARE MAY NOT
BE NEEDED.
WE MAY BE ABLE TO DO IT WITHIN A
PRIMARY CARE MODEL.
WE KNOW THE PARADIGMS HAVE
CHANGED IN THE LAST TWO DECADE.
WE'RE REALLY PULLING ADDICTION
CARE IN THE NORMAL HEALTH CARE
SETTINGS AND MAY MAY NOT BE
PEOPLE WHO ARE SPECIALTY
ADDICTION CARE.
IT COULD BE YOUR PRIMARY CARE
PROVIDER WITHIN THE CONFINES
WHERE YOU'RE SEEKING CARE ALL
THE TIME AND CAN POTENTIALLY
REDUCE STIGMA AND IMPROVE ACCESS
PARTICULARLY IN RESOURCE POOR
STUDIES LIKE RURAL HEALTH CARE
STUDIES WHERE A PRIMARY CARE
PROVIDER OR PHARMACIST MAY BE
ABLE TO ENGAGE WITH ADDITION
CARE.
IN MANY WAYS AS WE SWITCH THE
PARADIGM GETTING PROVIDERS TO
ACCEPT HOW TO DO THIS IN THE
SETTINGS IS AN IMPORTANT
CONSIDERATION.
WE'VE DONE WORK IN HEALTH CARE
SYSTEMS AND TALK ABOUT THE V.A.
SYSTEM.
THERE'S SYSTEM BARRIERS WITH
GETTING ADDITION CARE AND
THERE'S LACK OF EDUCATION,
THERE'S MAYBE ILL PERCEPTIONS
AND PERCEIVED LACK OF RESOURCES.
WHY SHOULD A PRIMARY CARE
PROVIDER DO THIS WHEN ADDICTION
CARE CLINIC MAY BE MORE RESOURCE
ED AND FACILITATORS WE LEARNED
IF YOU HAVE A CHAMPION, IF YOU
HAVE A PRIMARY CARE PERSON
WITHIN A LARGE HEALTH CARE
SYSTEM THE PRIMARY CARE
PROVIDERS AROUND THEM WILL
POTENTIALLY BE INTERESTED IN
DEALING WITH ADDITION CARE AND
DIRECTIVES HAVE BEEN IMPORTANT
COMPONENTS OF CHANGING LARGE
HEALTH CARE SYSTEMS AND THINK OF
ADDICTION CARE WITHIN MEDICAL
HEALTH SETTINGS.
WE'VE DONE WORK WITH DIRECTIVES
AND CRITERIA FOR USE.
ETCETERA.
THIS IS A SMATTERING OF A LOT OF
FORMALLY GUIDANCE WITH REGARD TO
BUPRENORPHINE AND GUIDANCE HAS
BEEN DIRECTED TO PRIMARY CARE
PROVIDERS NOT TO SUBSTANCE USE
DISORDER TREATMENT PROVIDERS BUT
THE AND THOSE WHO TAKE CARE OF
PATIENTS WITH ADDITION ON A
LONGITUDINAL BASIS.
AND THERE'S BEEN WORK ON
INCENTIVIZING PRIMARY CARE
PROVIDERS IN HOW TO DO THIS KIND
OF CARE.
THERE'S FINANCIAL INCENTIVES
SUCH AS EXTRA RESOURCES OR MONEY
ON A PAYCHECK OR BONUS PAY TO
PROVIDERS TO ENGAGE IN THIS
CARE.
THERE'S DIFFERENT TYPES OF
PROVIDERS WITH INCENTIVES.
IF YOU'RE A PHYSICIAN YOU MAY BE
INTERESTED IN MORE TIME WITH THE
PATIENT OR LESS CENSUS OF THE
PATIENT PANEL AND PROVIDE
BUPRENORPHINE IN THE PROVISION
OF THAT CARE.
INCENTIVES ARE AN IMPORTANT
COMPONENT THAT POTENTIALLY MAY
INCENTIVIZE PEOPLE TO PROVIDER
THIS TYPE OF CARE IN NORMAL
MEDICAL SETTINGS.
WE HAVE DONE A LOT OF WORK IN
THIS AREA LOOKING AT LARGE
SYSTEMS LIKE THE V.A. IS
PROVIDING THIS TYPE OF CARE AND
PARTICULARLY BUPRENORPHINE AND
THIS SLIDE SHOWS SINCE 2006 TO
2019 WE'VE HAD A STEADY INCREASE
IN THE AMOUNT OF PATIENTS
RECEIVING BUPRENORPHINE CARE AND
INITIATING TREATMENT WITHIN
VARIOUS HEALTH CARE SETTINGS.
THE PROBLEM WE FOUND EARLY ON IS
THAT EVEN IN A LARGE HEALTH CARE
SYSTEM WE SHUTTLE PEOPLE TO
SPECIALTY USE DISORDER CLINICS
WE NOTICED IN 2017 THOUGH WE'RE
DRIVING THIS IN THE SYSTEM AND
6% OF BUPRENORPHINE
PRESCRIPTIONS WERE PRESCRIBED BY
PRIMARY CARE PROVIDERS.
AS WE REDUCE THE COST OF
SPECIALTY CARE, HOW CAN WE
IMPROVE THE GENERALIST, THE
PRIMARY CARE PROVIDERS TO
PROVIDER THIS CARE TO REDUCE
COST AND POTENTIALLY IMPROVE
ACCESS OF CARE WHERE THERE MAY
NOT BE SUD CLINICS AROUND.
AND THERE WAS A STEP CARE
APPROACH SIMILAR TO THE CASCADE
OF CARE THROUGH THE NIH THE IDEA
WAS TO IMPROVE THE LEVELS OF
CARE AND TRANSITIONS FROM ONE
LEVEL OF CARE TO ANOTHER.
RECOGNIZING THE SUD SPECIALTY
AND IOPs AND RESIDENTIAL
TREATMENT PROGRAMS AND CAN WE
GET THE PRIMARY CARE PROVIDERS
AND PAIN CLINICAL PROVIDERS
PROVIDING CARE CAN WE HAVE THEM
ENGAGE IN TO ADDICTION CARE TO
IMPROVE ACCESS FOR THOSE
PATIENTS?
IN 2018 THERE WAS THE TRAIN THE
TRAINER TO TRY TO IMPROVE THE
ACCESS OF MEDICATION TREATMENT
FOR OPIOID USE DISORDER IN NON
SPECIALTY CARE SETTINGS.
PRIMARY CARE MENTAL HEALTH AND
PAIN CLINICS.
THROUGH FACILITATION METHODS, A
LOT OF EDUCATION STILL GOING ON
TODAY AS WELL AS AD HOC
CONSULTATIONS AND SITE VISITS WE
INITIATED THE SCOUT INITIATIVE
THROUGH 15 FACILITIES ACROSS THE
COUNTRY AND THIS IS CHANGING THE
CULTURE ASSOCIATED WITH HOW
WE'RE DRIVING FROM A 6% PRIMARY
CARE PROVISION OF BUPRENORPHINE
CARE TO WHAT WE'LL TALK ABOUT IN
THE NEXT SEVERAL SLIDES.
WE LEARNED EARLY ON IN THE FIRST
PHASE OF THIS PROJECT THAT BY
DOING THIS FACILITATION APPROACH
AND ENGAGING PROVIDERS IN
DIFFERENT FACILITIES WE'RE ABLE
TO INCREASE PROPORTIONALLY THOSE
RECEIVING CARE IN THE
NON-SPECIALTY CARE SETTINGS
EMBOLDENED TO EXPAND ACROSS THE
COUNTRY.
>> THIS IS THE TAKE HOME POINT
TO CHANGE THE SYSTEM TO DRIVE
THE CHANGE TO IMPROVE ACCESS
WITHIN NON-SPECIALTY CARE
SETTINGS.
IF YOU SEE ON THE SLIDE FROM
2016 TO 2024, THE BLUE BAR IS
THE SUD CLINICS AND THE
PROVISION OF ALL BUPRENORPHINE
SYSTEMS IN THE V.A.
YOU SEE THIS PROPORTIONATELY
DECLINED OVER TIME SUCH THAT IF
YOU SEE IN 2024, 56% OF ALL
PRESCRIPTIONS ARE WITHIN SUD
SPECIALTY CARE CLINICS AND THE
REST, 44% IN NON-SPECIALTY CARE
SETTING WITH INCREASING AMOUNT
OF PRIMARY CARE AND MENTAL
HEALTH CLINICS AND PROVIDER
LONGITUDINAL WRAP AROUND CARE
AND THE CHRONIC BRAIN DISEASE
TREATMENT WE KNOW SUD REQUIRE.
THE OTHER THING THAT WAS EXC
EXCITING WE FOUND ON THE PROJECT
IS WE'VE STARTED TO SEE MORE
INITIATIONS AND THE PRIMARY CARE
AND PAIN CLINIC PROVIDERS TAKE
OVER THE CARE OVER TIME.
AND THEY'RE INITIATING CARE SUCH
THAT IN 2023 WE HAD MORE
INITIATIONS OF EPISODES OF CARE
FOR BUPRENORPHINE CARE AND
EXCITING TO SEE IT HAPPEN
RAPIDLY.
WE'RE NOT GOING TO TALK ABOUT
ALL THE MODELS OF CARE.
WE TALK ABOUT INTEGRATIVE CARE
BUT IN A PRIMARY CARE MODEL YOU
CAN ENGAGE PROVIDERS IN THE
PROVISION OF THE CARE UNDER
NURSE MANAGEMENT OR PHARMACIST
OR SOCIAL WORKER.
AND YOU HAVE PHARMACISTS WORKING
ALONGSIDE PRESCRIBERS WHO ARE
DOING THE MONITORING AND
ENGAGEMENT AROUND DAY TO DAYCARE
FOR A PATIENT CURRENTLY ON
BUPRENORPHINE.
YOU CAN SEE WE'VE DONE WORK IN
UNDERSTANDING HOW PHARMACISTS CA
CAN PRESCRIBE BUPRENORPHINE IN
STATES THAT ALLOW THEM TO
PRESCRIBE AND A LOT OF
PHARMACISTS ARE INDEPENDENT IN
PROSCRIBING BUPRENORPHINE CARE
AND DOING A GOOD JOB.
THE RATE OF RETENTION IS ABOUT
87% AFTER A 90-DAY PERIOD.
VERY EXCITING TO SEE THAT.
OTHER HEALTH CARE PROVIDERS ARE
ABLE TO PROVIDE CARE IN A
MEDICAL HOME MODEL.
I DIDN'T TALK A LOT ABOUT THE
FINANCIAL COSTS SO WHAT WE'RE
SEEING WE CHANGED THIS AND
SPECIALTY CARE IS A LOT MORE
EXPENSIVE AND A METHADONE CLINIC
OR SPECIALTY CARE CLINIC IS MORE
EXPENSIVE THAN A PRIMARY CARE
CLINIC THIS ONE SHOWS DECREASED
UTILIZATION OF PATIENT AND
EMERGENCY ROOM USE DOES OCCUR
DURING THE MODEL AND DOWN STREAM
COSTS ARE LESS AND IT'S A GREAT
OPPORTUNITY TO SEE HOW WE EXPAND
TO HEALTH CARE SYSTEM AND SAVE
MONEY AND EVALUATE THE COST PER
TYPE OF PATIENT THAT COMES.
WITH THAT I'LL PASS IT OFF TO
THE NEXT PERSON.
THE LAST THING I'LL MENTION IS
THERE'S A LOT OF WAYS TO DO
HEALTH CARE FOR PATIENTS WITH
ADDITION AND ONE MODEL IS
INTEGRATED WITHIN NORMAL
SETTINGS AND THE RETENTION RATES
ARE SIMILAR TO SPECIALTY CARE
AND COSTS ARE LESS AND WE'RE
EXCITED TO CONTINUE THIS WORK
GOING FORWARD AND AGAIN I THANK
THE NIH AND DEPARTMENT OF
VETERANS FOR FUNDING THIS WORK.
THANK YOU.
>> NEXT IS DR. MARA FROM T.H.
CHAN SCHOOL OF PUBLIC HEALTH.
>> THANKS TO THE ORGANIZERS AND
PARTICIPANTS.
IT'S GREAT TO BE HERE.
I'VE TRIED TO TAKE CONTROL.
>> I WANT TO ACKNOWLEDGE THE
WORK IS REALLY THERE'S A LARGE
TEAM BEHIND THE WORK AND I'M
SUPER GRATEFUL FOR FUNDING FROM
NIDA AND NIMHD FOR SUPPORTING
THIS WORK.
IN WAY OF PUBLIC CONTRACTS SO
CONTRACTS WITH MEDICAID AND
MEDICARE AND PROVIDER
ORGANIZATIONS SERVE MANY
INDIVIDUALS WITH BEHAVIORAL
HEALTH DISORDERS THESE CONTRACTS
GIVE ORGANIZATIONS INCENTIVES TO
MEET SPENDING AND QUALITY
BENCHMARKS FOR A DESIGNATED
PATIENT POPULATION.
AND IT LEARN ABOUT FEATURES OF
THE CONTRACTS AND WHAT
ORGANIZATIONS ENTERING CONTRACTS
CAN DO WE SURVEYED ACO LEADERS
AND COMPLIMENTED THE WORK WITH
ANALYSES IN MEDICARE AND
MEDICAID CLAIMS.
TODAY I'LL FOCUS ON ONE PAPER.
I'LL PUT IT IN THE CONTEXT OF
THE LARGER RESEARCH AGENDA IN
THE SPIRIT OF THE SESSION ON
PROVISION AND DIGITAL
TECHNOLOGIES I'M LOOKING AT THE
FOLLOWING PAPER LED BY CHRIS
MILLER ROSALES.
SO THE BACKGROUND FOR THIS IS WE
ALL KNOW AND MENTIONED IN THE
INTRODUCTION THERE'S RELATIVELY
LOW USE OF MANY EVIDENCE-BASED
APPROACHES TO TREATING OPIOID
USE DISORDER AND REACH THE
DISORDER PARTICULARLY IN PLACES
THAT MIGHT OTHERWISE NOT HAVE AS
MANY RESOURCES OR PROVIDERS
AVAILABLE.
IN A SETTING OF ACO
PARTICIPATING ORGANIZATIONS SO
SURVEY RESPONDENTS OF THOSE, WE
ASKED ABOUT THESE FEATURES.
THAT'S WHAT I'LL BE TALKING
ABOUT TODAY.
THE NATIONAL SURVEY OF ACOs IN
THE 2021 HOLDING MEDICARE OR
MEDICAID ACO CONTRACTS WE ASKED
ABOUT THE STRUCTURE OF THE
ORGANIZATION, THE CONTRACTS AS
WELL AS CAPABILITIES ESPECIALLY
AS THEY RELATED TO TREATMENT OF
OPIOID USE DISORDER AND THE
RESPONDENTS' WHOLE LEADERSHIP
ROLES IN THE ORGANIZATIONS.
WE RECEIVED RESPONSES FROM 276
ORGANIZATIONS WHICH WAS ABOUT A
55% RESPONSE RATE.
SO IN THIS STUDY WE LOOKED AT
THREE DIGITAL HEALTH
TECHNOLOGIES FOR OPIOID USE
DISORDER, REMOTE MENTAL HEALTH
THERAPY AND TRACKING, PEER
RECOVERY SUPPORT PROGRAMS AND
DIGITAL RECOVERY SUPPORT FOR
ADJUVANT CBT.
TO GIVE A FLAVOR OF HOW WE ASKED
ORGANIZATIONS I WON'T GO THROUGH
THIS IN A DETAILED WAY BUT
BASICALLY ASKED DO CLINICIANS
USE THESE TO INTEGRATE TREATMENT
OR OUD OR MENTAL ILLNESS OR ARE
YOU JUST USING THE TOOLS.
AND YOU CAN THINK OF THINGS LIKE
BETTER HEALTH AND SIMILAR TOOLS
AND PEER RECOVERY SUPPORT AND
SMART RECOVERY GROUPS AND THEN
THE FINAL ONE INCLUDES
TECHNOLOGIES LIKE RESET O WHICH
HAS BOTH APPROVED BY THE FDA FOR
USE AND HAS SOME EVIDENCE OF
IMPROVING ADHERENCE AND
TREATMENT OF OUD BUT THIS IS
REALLY TO HELP FOLKS GET CBT IN
ADDITION TO THERAPY FOR OUD.
DESCRIPTIVELY WHAT DID WE LEARN
FROM ORGANIZATIONS ABOUT
REPORTING USE OF IT.
ACTUALLY A THIRD OF
ORGANIZATIONS REPORTED USING AT
LEAST ONE OF THESE.
THE MOST COMMON BEING THE MENTAL
HEALTH THERAPY AND TRACKING.
THE LEAST COMMON THE DIGITAL
RECOVERY SUPPORT.
AND SO THAT WAS NOTABLE TO US.
WE WEREN'T SURE HOW OFTEN THEY
WOULD BE USED.
THE SECOND PART TO ANSWER THE
SECOND PIECE OF THIS QUESTION
WOE WANTED TO ESTIMATE USE OF
THESE THERAPIES OR ANY OF THE
THREE.
AS A FUNCTION OF WHETHER
ORGANIZATIONS REPORTED HAVING
DIFFERENT TRADITIONAL SUD
TREATMENT RESOURCES.
AND WE EXPECT A POSITIVE
RELATIONSHIP BETWEEN SUBSTANCE
USE DISORDER AND WE'LL ACCOUNT
FOR OTHER CHARACTERISTICS.
THE SUD AND DOES YOUR
ORGANIZATION INCLUDE AN
ADDICTION MEDICINE SPECIALIST?
DO YOU BELIEVE YOU HAVE
SUFFICIENT STAFF TO TREAT?
DO YOU OFFER MEDICATIONS FOR
OPIOID USE DISORDER?
DOES YOUR LARGEST ACO HAVE OUT
PATIENT OR IN PATIENT OR
RESIDENTIAL AND DO YOU USE
DASHBOARDS TO FACILITATE OPIOID
USE DISORDER.
THE OTHER CHARACTERISTICS ARE
THE ORGANIZATION TYPE OF THE
RESPONDENT AND WHAT THE
RESPONDER REPORTS ABOUT
STAFFING, SPECIALIZED TRAINING
OR OTHER COSTS AS BARRIERS TO
DELIVERING MENTAL HEALTH AND
SUBSTANCE USE TREATMENT.
WHETHER THEY HAD A MANAGEMENT
PARTNER.
THINK OF CARAVAN THAT HELPS WITH
THE ACO CONTRACTFY FEATURE
CONTRACT FEATURES AND HOW THEY
TOOK THE SURVEY.
WHAT DID WE LEARN?
WE LEARNED LOGISTIC REGRESSIONS
WHAT WE'RE REPORTING ARE
MARGINAL AFFECTS.
THAT MEANS LOOKING AT THIS FIRST
COLUMN IT'S A PERCENTAGE POINT
CHANGE.
IF YOU REPORTED YOUR
ORGANIZATION HAD AN ADDITION
SPECIALIST YOU WERE 44
PERCENTAGE POINTS MORE LIKELY TO
USE A DIGITAL TECHNOLOGY ON A
BASELINE OF 23%.
SO A PRETTY BIG EFFECT.
AND THE PATTERN IS SIMILAR NO
MATTER THE TECHNOLOGY.
THERE'S A LITTLE BIT LESS OF A
LARGER EFFECT WHEN YOU'RE
LOOKING AT SOMETHING LIKE
DIGITAL RECOVERY SUPPORT.
AND I WANT TO POINT OUT OTHER
CHARACTERISTICS OF ACO
ORGANIZATIONS AND HEALTH SYSTEMS
OR PHYSICIAN OR MEDICAL LED
ORGANIZATIONS ARE ME MOST LIKELY
TO ADOPT EACH OF THESE THERAPIES
AND IF YOU LOOK AT SAVED A NET
ORGANIZATIONS THEY'RE LESS
LIKELY TO ADOPT SOMETHING LIKE
REMOTE MENTAL HEALTH THERAPY AND
TRACKING.
THAT STOOD OUT TO US.
FROM THIS STUDY WE FOUND ABOUT
ONE-THIRD OF ACOS USE THESE AND
THEY'RE COMPLEMENTS TO OTHER SUD
RESOURCES.
THE ORGANIZATIONS WITH ADDICTION
SPECIALIST USING REGISTRIES WERE
THE ONES MOST LIKELY TO ADOPTS
SOMETHING LIKE SAFETY NET
ORGANIZATIONS OR INCLUDING A
SAFETY NET HOSPITAL OR RQFDs
WERE LESS LIKELY TO USE THE
TECHNOLOGIES.
SO I JUST WANTED TO USE THIS TO
PUT IT IN THE CONTEXT OF WHAT
WE'VE BEEN LEARNING ABOUT THESE
PAYMENT AND DELIVERY MODELS OF
ACOS IN THE CONTEXT OF
BEHAVIORAL HEALTH.
EVEN IN THE ORGANIZATIONS OF ACO
PARTICIPANTS MORE FOCUSSED ON
POPULATION HEALTH THAN OTHERS,
THE EVIDENCE-BASED BEHAVIORAL
HEALTH APPROACHES ARE USED AT
LOWER RATES THAN HOPED.
THAT'S TRUE FOR COLLABORATIVE
CARE AND IMMUNOINTEGRATION OF
BEHAVIORAL HEALTH AND TRUE FOR
MEDICATIONS FOR OPIOID USE
DISORDER.
THE ADOPTION OF MOUD IS
IMPROVING OVER TIME.
AND AFTER ENTERING AN AC SCRO
CONTRACT, SPENDING DOESN'T RISE
BUT QUALITY TENDS TO IMPROVE AND
WE FOUND FEATURES WITH
INTEGRATION AND QUALITY
MEASURES, BEHAVIORAL HEALTH
INTEGRATION OF BEHAVIORAL HEALTH
PROVIDERS IN YOUR ACO AND I'M
OUT OF TIME BUT ESSENTIALLY AS
WITH OTHER PRACTICES ADOPTION OF
THESE TECHNOLOGIES IS LOW.
WE MAY NEED TO SUPPORT
ORGANIZATIONS OR PEOPLE WITH
LOWER RESOURCE TO ADOPT NEW
TECHNOLOGIES AND WE CONTINUE TO
LOOK AT HOW THEY OPERATE IN THE
COMMUNITY.
THANK YOU.
>> NEXT WE HAVE DR. JOHNSON FROM
WASHINGTON UNIVERSITY IN
ST. LOUIS.
>> THANK YOU.
THANKS FOR TAKING TIME TO TUNE
INTO MY TALK TODAY.
I'M GOING TO TALK ABOUT MENTAL
HEALTH CARE AND RISK BASED
PAYMENT FOR PATIENTS WITH
DEPRESSION-ANXIETY DISORDERS.
I WANT TO ACKNOWLEDGE MY TEAM OF
CO-INVESTIGATORS THAT ARE
WONDERFUL TO WORK WITH AND
SUPPORT FOR THE RESEARCH FROM
THE NIMHD.
THE CONTENT I'M GOING TO
REPRESENT ARE MY OWN VIEWS AND
CO-AUTHORS AND NOT OFFICIAL
VIEWS OF THE NIH.
A QUICK AGENDA.
FIRST I WANT TO TEE UP WHY RISK
BASED PAYMENT IS IMPORTANT AND
DELVE INTO OUR EARLY RESEARCH ON
RISK ADJUSTMENT AND COST
PREDICTION FOR BENEFICIARIES
WITH DEPRESSION AND ANXIETY AND
WHAT THIS MIGHT MEAN FOR PAYMENT
OF PRACTICES, PAYMENT OF ACOS
AND MEDICARE ADVANTAGE PLANS.
WHY IS RISK BASED PAYMENT
IMPORTANT IN MEDICARE?
I THINK THE MOST SIMPLE REASON
IS FOUR IN FIVE MEDICARE
BENEFICIARY NOW UNDER SOME FORM
OF RISK BASED PAYMENT.
MORE THAN HALF OF ALL
BENEFICIARIES IN THE MEDICARE
PROGRAM ARE ENROLLED IN MEDICARE
ADVANTAGE PLANS WHICH ARE PAID
UNDER CAPITATION, INSURANCE
PLANS AND SO THAT IS BASED ON
THE RISK PROFILE AND BENEFI
BENEFICIARIES THEY ENSURE.
IN THE ORIGINAL FEE FOR SERVICE
MEDICARE PROGRAM, CURRENTLY OVER
HALF OF MEDICARE BENEFICIARIES
ARE ALSO ENROLLED IN ACCOUNTABLE
CARE ORGANIZATIONS.
AND THEY'RE ALL PAID UNDER SOME
FORM OF RISK BASED PAYMENT.
THERE'S PAYMENT AND LOSSES AND
BENCHMARKS AND REGIONAL AND
HISTORIC BENCHMARKS BUT THEY'RE
BASED ON RISK ADJUSTED COST AND
THE RANGE OF RISK CAN VERY FROM
VERY LITTLE TO MORE AND MORE
WHICH IS INCREASINGLY THE CASE
SHARED LOSSES AND TAKING ON A
LOT OF RISK AS IN THE CASE OF
SOME ACOs IN THE REACH PROGRAM.
THE OTHER THING I'LL ADD AND MID
CARE ADVANTAGE PLANS AND ACC
ACCOS -- ACOS.
CONCEPTUALLY THE REASON IT'S
IMPORTANT WHEN IT CO MZ TO
PAYING ENTITIES THAT BEAR RISK
IS WE'RE NOT IN A SITUATION
WHERE ONE INSURER INSURES THE
ENTIRE COMMUNITY LIKE USED TO BE
THE CASE WITH BLUE CROSS, BLUE
SHIELD OR GOING UP TO CANADA
WITH THE PROVIDENCE OF ONTARIO
AND EACH ACO HAS A SEPARATE
GROUP OF PATIENTS WITH THEIR OWN
UNIQUE SET OF SOCIAL AND MENTAL
AND MEDICAL RISK FACTORS.
BASED ON THAT PANEL OF PATIENTS,
THE ACO'S PANEL OR PATIENT PANEL
WILL NEED CERTAIN HEALTH CARE
RESOURCES.
THOSE ARE LARGELY DRIVEN BY THE
RISK FACTORS.
THEY'LL RESULT IN DIFFERENT
HEALTH CARE RESOURCES USED AND
DIFFERENT COSTS INCURRED BY
PATIENTS.
IT'S IMPORTANT TO ADJUST FOR THE
UNDERLYING RISK FACTORS WHEN
PAYING ENTITIES THAT BEAR RISK
WHETHER THAT'S INSURANCE PLANS
OR ACOs AT LEAST PARTIALLY IN
THE TRADITIONAL MEDICARE
PROGRAM.
THE WAY RISK ADJUSTMENT IS DONE
IS THE HIERARCHICAL RISK
ADJUSTMENT CATEGORIES MODEL.
WE COULD HAVE A NERDY ARGUMENT
ALL DAY ABOUT THE MODEL BUT TO
SPEAR -- SPARE YOU THAT BUT THIS
IS BASED ON THE AGE, SEX,
MEDICARE ENTITLEMENT, MEDICAID
ENROLLMENT AND
INSTITUTIONALIZATION AND 115
COMORBIDITIES AND LOOK AT THE
CLAIMS REFLECTED IN THE 115
COMORBI
COMORBIDITIES.
MANY DEPRESSION AND ALL ANXIETY
DIAGNOSES ARE NOT INCLUDED IN
THE MODEL.
AND THE DIAGNOSES CONSIDERED
DISCRETIONARY BY SOME ARE
TYPICALLY EXCLUDED FROM THE
MODEL AND RIGHT NOW CMS
CONSIDERS MILDER FORMS OF
DEPRESSION AND ANXIETY TO BE
DISCRETIONARY DIAGNOSIS.
PREVIOUSLY THIS WAS ALSO TRUE OF
DEMENTIA.
WITHIN WAY TO THINK OF IT AS A
RISK MODEL IS COST PREDICTIVE
MODEL.
IT PREDICTS COST AT THE
BENEFICIARY LEVEL AND HOW
ACCURATELY THEY'RE PREDICTED IN
WHOLE GROUPS OF PEOPLE.
IT'S IMPOSSIBLE TO ACCURATELY
PREDICT COST S COSTS AT THE BENY
LEVEL.
THAT'S WHY WE HAVE INSURANCE IN
THE FIRST PLACE.
WHAT MATTERS IS HOW ACCURATE THE
MODEL IS IN PREDICTING COST IN
LARGE GROUPS OF PATIENTS.
WE CAN UNDERSTAND THIS BY
COMPARING PATIENTS ACTUAL
OBSERVE COST TO WHAT THEY WERE
EXPECTED TO BE.
IT'S IMPORTANT THE COSTS AND
EXPECTED COSTS ARE CLOSE IN
LARGE SUB GROUPS OF PATIENTS
DEFINED BY DIFFERENT CONDITIONS
THAT DRIVE COSTS.
FOR EXAMPLE, PATIENTS WITH HEART
FAILURE ARE GOING TO COST MORE
ON AVERAGE THAN YOUR TYPICAL
PATIENT.
WE WANT TO OBSERVE POST AND
EQUAL EXPECTED COST ON AVERAGE.
IF THEY DON'T, THIS CREATES
INCENTIVES FOR INSURED RISK
BEARING ENTITY TO AVOID INSURING
PATIENTS LIKE THAT OR SKIMP ON
TREATMENT BECAUSE THEY'LL LOSE
MONEY AND THERE'S BEEN ONGOING
RESEARCH AND TENDS TO UNDER
PREDICT COST FOR CERTAIN GROUPS
OF PATIENTS.
THE GRAPHIC SHOWING A PRIOR
STUDY SHOWING COSTS FOR PATIENTS
WITH HIGHER LEVELS OF FRAILTY.
I'LL LOOK AT RISK ADJUSTMENT AND
PREDICTION FOR DEPRESSION AND
ANXI
ANXIETY.
DEPRESSION AND ANXIETY ARE
PREVALENT AND BURDENSOME AND
COSTLY.
UP TO 30% OF MEDICARE
BENEFICIARIES HAVE AT LEAST ONE
OF THESE CONDITIONS.
THE PER CAPITA SPENDING TENDS TO
BE SUBSTANTIALLY HIGHER THAN
PATIENTS WITHOUT THE CONDITIONS.
THE OTHER IMPORTANT THING TO
NOTE IS DEPRESSION AND ANXIETY
ARE UNDER DIAGNOSED AND TREATED
AND MORE THAN HALF ARE NOT
RECEIVING ANY TREATMENT.
THAT'S PARTLY BECAUSE OF ACCESS
TO MENTAL HEALTH CARE AND THE
LACK OF ACCESS IS A NATIONAL
CRISIS IN MEDICARE AND
ELSEWHERE.
HERE WE HAVE TWO QUESTIONS WE
LOOKED AT SO FAR WHICH ONE ARE
DEPRESSION AND ANXIETY DISORDERS
ASSOCIATED WITH MEDICARE COSTS
UNEXPLAINED BY MEDICARE'S RISK
ADJUSTMENT MODEL.
TWO, DOES THE MODEL SYSTEMICALLY
OVER OR UNDER PREDICT COSTS FOR
BIG SUB GROUPS OF BENEFICIARIES
WITH AND WITHOUT THE DISORDERS.
WE FOCUSSED ON ALL COMMUNITY
DWELLING MEDICARE FEE FOR
SERVICE USING THE CHRONIC
UKRAINE WAREHOUSE.
WE FOCUSSED ON THOSE
CONTINUOUSLY ENROLLED IN
TRADITIONAL MEDICARE IN 2022 AT
LEAST UP TO DEATH AND A FULL
YEAR OF BASELINE 2021 ENROLLMENT
ELIGIBLE FOR ACO DISTRIBUTION.
WE USED THE CHRONIC CONDITION
FLAGS AT BASELINE AT YEAR 2021
TO IDENTIFY PATIENTS WITH
DEPRESSION AND/OR ANXIETY AND
THE PREVALENCE RATE IN THIS
STUDY POPULATION JUST UNDER 23
MILLION BENEFICIARIES WAS 26%.
AND FROM THIS WE CREATED FOUR
GROUPS.
THOSE WITH DEPRESSION AND NO
ANXIETY AND ANXIETY AND
DEPRESSION AND NONE.
WHEN WE LOOKED AT THE GROUPS
DESCRIPTIVELY JUST BY THEIR
TOTAL COST OF CARE, PART A AND B
PAID COSTS BY MEDICARE.
WHAT WE FOUND IS THOSE IN THE
THREE DEPRESSION AND/OR ANXIETY
GROUPS COST 31% TO 99% HIGHER ON
AVERAGE COMPARED TO
BENEFICIARIES WITHOUT THESE
CONDITIONS.
WE COMPUTED THEIR RISK SCORES
BASED ON THE MOST RECENT VERSION
WITH CMS AND FOUND BENEFICIARIES
WITH DEPRESSION AND ANXIETY HAD
APPROXIMATELY 23% TO 74% HIGHER
MEAN RISK SCORES WHICH REFLECTS
THEIR UNDERLYING BURDEN OF ANY
COMORBIDITIES THE RISK SCORES
MEASURE.
THE BENEFICIARIES ARE ALSO MORE
LIKELY TO BE DULY ENROLLED IN
MEDICAID.
MORE LIKELY TO HAVE DISABILITY
VERSUS AGE ENTITLEMENT IN
MEDICARE.
WE LOOKED AT THE RESIDUAL AMOUNT
BY THE MODEL.
THESE ARE THE UNEXPLAINED COSTS
AND USE THOSE AS DEPENDENT
VARIABLES REGRESSING THOSE AS
INDICATORS AT THE BENEFICIARY
LEVEL WHETHER PEOPLE HAD
DEPRESSION WITHOUT ANXIETY,
ANXIETY WITHOUT DEPRESSION OR
BOTH DEPRESSION AND ANXIETY.
AND WHAT WE FOUND IS THAT THESE
CONDITIONS ARE ASSOCIATED WITH
SUBSTANTIAL RESIDUAL COST NOT
EXPLAINED BY THE RISK FACTORS IN
THE STANDARD CMS MODEL AND
COMPARE THIS VERSUS WHAT THE
AVERAGE COST BENEFICIARY OF
COSTLY $12,082 AND THE UNDER
PREDICTION RANGED FROM 88.3% FOR
THOSE WITH ANXIETY AND
DEPRESSION TO 24% FOR THOSE WITH
BOTH CONDITIONS.
THE SECOND PART OF OUR QUESTION
IS IS THE MODEL SYSTEMICALLY
UNDER OR OVER PREDICT COSTING
WITH AND WITHOUT THE CONDITIONS.
WE COMPUTED THE OBSERVED MINUS
EXPECTED COSTS FOR DIFFERENT
GROUPS OF BENEFICIARIES.
AGAIN IF YOU'RE OBSERVED COST
MORE THAN YOUR EXPECTS COSTS.
IF YOU'RE ENSURING THE
BENEFICIARIES WILL LOSE MONEY
BUT IF YOU'RE OBSERVED COSTS ARE
LESS YOU'LL MAKE MONEY AS A RISK
BEARING ENTITY.
WHAT WE FOUND IS THE MODEL IS
OVER PREDICTING COSTS FOR
BENEFICIARIES WITHOUT DEPRESSION
AND ANXIETY AND COST $466 THAN
THEY'RE EXPECTED TO AND THE
MODELS UNDER PRE DICTING COSTS
FOR BENEFICIARIES WITH
DEPRESSION AND ANXIETY.
THE UNDER PREDICTION RANGES FROM
$479 ON AVERAGE FOR THOSE WITH
ANXIETY AND NO DEPRESSION TO
$910 FOR DEPRESSION AND NO
ANXIETY AND $1271 WITH
DEPRESSION AND ANXIETY.
WE ALSO LOOKED AT THESE --
>> WE NEED TO JUMP AHEAD A
LITTLE BIT.
>> LET'S GO TO THE LAST SLIDE,
THE TAKEAWAYS.
THE BASIC TAKEAWAY THERE APPEARS
TO BE SOME COST IS UNDER
PREDICTED AND THAT CAN IMPACT
PRIMARY CARE PRACTICES WHERE A
LOT OF THESE PATIENTS ARE CARED
FOR.
IF A PRACTICE HAS A HIGH CASE
LOAD OF PATIENTS LIKE THIS
THEY'LL BE LESS ATTRACTIVE FOR
AN ACO TO CONTRACT WITH OR
INCLUDE IN THEIR ACO.
AND MEDICARE INCREASINGLY MOVES
TO RISK-BASED PAYMENT.
THANKS A LOT.
>> THANK YOU.
OUR FINAL PRESENTER IS DR
DR. MEHROTRA FROM BROWN
UNIVERSITY.
>> THANK YOU EVERYONE WHO
ORGANIZED THE PANEL AND THE DAY
AS A WHOLE.
I'M EXCITED TO PRESENT ONE PAPER
IN A LARGER BODY OF WORK ON
TELEMEDICINE AND ITS ROLE IN
TREATING PATIENTS WITH MENTAL
ILLNESS AND SUBSTANCE USE
DISORDER.
WHEN PEOPLE SAW THE RAPID GROWTH
OF TELE MEDICINE WAS CONSIDERED
A SILVER LINING OF THE PANDEMIC.
WHEN PEOPLE THOUGHT OF
TELEMEDICINE THEY SAID IT COULD
BE MORE PATIENT CENTRIC AND
IMPROVE OUTCOMES FOR CHRONIC
ILLNESS AND SAVE US MONEY AND
MAYBE MOST IMPORTANTLY OR WHERE
THE FOCUS WAS THIS CAN IMPROVE
ACCESS TO THOSE WHO REALLY
STRUGGLE TO GET CARE.
THIS CAME UP RECENTLY IN
DR. OZ'S CONFIRMATION HEARING
WHEN SENATOR HAINES ASKED HOW TO
IMPROVE ACCESS, DR. OZ SAID WE
CAN USE TELEMEDICINE TO IMPROVE
ACCESS TO CARE TO PEOPLE IN
RURAL COMMUNITIES IN MONTANA.
IN PARTICULAR FOR MENTAL
ILLNESS.
AND HE HIGHLIGHTED WIDE
DISPARITIES IN MENTAL HEALTH USE
BETWEEN URBAN AND RURAL AREA AND
PARTLY DRIVEN BY SUPPLY.
MANY IN RURAL COMMUNITIES DON'T
HAVE A PSYCHIATRIST OR OTHER
MENTAL HEALTH PROFESSIONAL IN
THEIR COMMUNITY AND MAYBE
TELEMEDICINE CAN BE PART OF THE
SOLUTION AND MENTAL ILLNESS IS
WELL SUITED AND A CLINICIAN FROM
A CITY COULD NOW TREAT A PATIENT
IN A RURAL AREA.
THAT'S BEEN THE HOPE.
THAT'S WHAT I'VE BEEN EXCITED
ABOUT.
THE QUESTION WE'LL ANSWER IN
THIS PAPER IS HAS THAT HAPPENED.
HOW WILL WE ANSWER THIS
QUESTION?
WE'LL TAKE ROUGHLY 18,000 MENTAL
HEALTH SPECIALISTS CARING FOR
PATIENTS OVER THIS SIX-YEAR TIME
HORIZON.
THE 18,000 MENTAL HEALTH
CLINICIANS WE'LL DIVIDE INTO
QUARTILES BASED ON HOW MUCH
TELEMEDICINE THEY USED IN 2021
FROM THE HIGHEST QUARTILE LOVING
THE TELEMEDICINE TO THOSE IN THE
LOWEST QUARTILE.
THEN COMPARE THEIR CARE PATTERNS
AND PATIENTS TREATED IN 2018 AND
'19 AND WHAT VISITS THEY HAVE IN
'22 AND '23.
THE HYPOTHESIS IS THOSE WHO
EMBRACED TELEMEDICINE WILL BE
CARING FOR MORE PATIENTS IN
RURAL COMMUNITIES DISTANT FROM
THEM.
I'M TALKING ABOUT PSYCHIATRIST
AND SOCIAL WORKERS AND
PSYCHIATRIC NURSE PRACTITIONERS
AND IDENTIFYING THEIR VISITS
USING CPT CODES ONE VISIT A DAY.
WE'RE NOT GOING TO LOOK AT ALL
MENTAL HEALTH SPECIALISTS.
WE'LL EXCLUDE THOSE LOW VOLUME
OR MOVED WHAT PRACTICE THEY WERE
IN OR GEOGRAPHIC LOCATION OR
USING TELEMEDICINE BEFORE 2020.
THEY'VE BECOME TELEMEDICINE
HEALTH SPECIALISTS AND THESE
MENTAL HEALTH ARE USING
TELEMEDICINE TO SOME DEGREE.
HOW DO YOU OPERATIONALIZE
GEOGRAPHIC REACH?
WE'RE LOOK AT PRIMARY OUTCOMES.
WE'LL LOOK AT WHAT TRACTION OF
THEIR VISITS ARE FOR PATIENTS IN
COUNTIES WITH NO PRACTICING
PSYCHIATRISTS AND PUBLIC HEALTH
SHORTAGE AREA AND PATIENTS IN
RURAL COMMUNITIES AND PATIENTS
WITH A DIFFERENT STATE OR FAR
AWAY AND WE'RE USING AN
ARBITRARY CUT OFF OF 20 MILES
AND LOOKED AT OTHER CUT-OFFS AND
RESULTS WERE SIMILAR.
AS A SECONDARY OUTCOME, WHAT
WE'RE HOPING IS NEW PATIENTS
FROM RURAL COMMUNITIES WILL BE
ENTERING THE PRACTICES.
WE NEED TO KNOW HOW MANY NEW
PATIENT SLOTS ARE THERE.
WE'LL LOOK AT WHAT FRACTION OF
VISITS IN A GIVEN TIME PERIOD
ARE FOR NEW PATIENTS.
LET'S SAY I HAVE MORE PATIENTS
FROM ANOTHER STATE.
IS THAT BECAUSE SEEING A NEW
PATIENT FROM ANOTHER SCAPE OR
MAYBE BECAUSE MY EXISTING
PATIENT MOVED CLOSER TO FAMILY
AND SO FORTH.
IS IT A REFLECTION OF CONTINUITY
MUCH CARE.
IN A SECONDARY ANALYSIS WE'LL
KEEP PATIENTS' LOCATIONS FIXED
AS A WAY TO DISENTANGLE THIS
EVENT.
NOW, THESE ARE THE
CHARACTERISTICS FOUR FROM LOWEST
TELEMEDICINE USE TO HIGHEST.
I WANT TO HIGHLIGHT DIFFERENCES
HERE.
THE HIGH ONES ARE MORE LIKELY TO
BE IN URBAN AREAS AND IN THE
NORTHEAST AND LESS LIKELY TO
CARE FOR PATIENTS WITH
DISABILITY OR LOW INCOME.
THESE DIFFERENCE REFLECTED IN
SOME OF THE OUTCOMES.
THIS IS THE FIRST OUTCOME.
WHAT FRACTION OF THE PATIENT
VISITS ARE FOR PATIENTS LIVING
IN A MENTAL HEALTH SHORTAGE AREA
WHERE THERE'S NO PSYCHIATRISTS.
ON THE X AXIS IS THE TIME PERIOD
FROM 2018 TO 2023.
AND THE DIFFERENT COLORS THE
HIGHEST TELEMEDICINE CLINICIANS
AT THE BASELINE WERE SEEING
FEWER PATIENTS FROM SHORTAGE
AREAS IN CONTRAST TO THE HIGHEST
UP ON THE TOP THE LOWEST
TELEMEDICINE GROUP.
CHANGES OVER TIME.
THAT'S HARD IT SEE LOOKING AT
THESE GRAPHS.
IF YOU CLICK ONCE WHAT WE'RE
DOING HERE IS NOW CHANGING THIS
RELATIVE TO THEIR BASELINE RATE
IN 2018.
WHEN YOU LOOK AT IT FROM THIS
WAY, YOU CAN SEE OVER TIME WE
REALLY HAVEN'T SEEN ANY CHANGE
IN THE FRACTION ACROSS THE
QUARTILES AND THE PATIENTS
COMING FROM MENTAL HEALTH
SHORTAGE AREAS.
LET'S LOOK AT ANOTHER OUTCOME.
RURAL PATIENTS.
HIGHEST TELEMEDICINE.
CLINICIANS WHO EMBRACED IT MOST
WERE LEAST LIKELY TO CARE FOR
RURAL PATIENTS AT BASELINE.
OVER TIME WE SEE A LITTLE
INCREASE IN THEIR LIKELIHOOD OF
CARING FOR THEM RELATIVE TO
OTHER GROUPS BUT THE DIFFERENCES
ARE SMALL.
IF YOU LOOK AT THE Y AXIS THESE
ARE PERCENTAGE POINT
DIFFERENCES.
THE DIFFERENCE IS QUITE SMALL.
THIRD OUTCOME WERE PATIENTS WERE
FURTHER AWAY.
HERE WE START TO SEE A LITTLE
BIT OF A DIFFERENCE.
THE CLINICIAN WHO EMBRACED
TELEMEDICINE START TO SEE MORE
PATIENTS FROM FURTHER AWAY
COMPARED TO THOSE WHO EMBRACED
TELEMEDICINE TO A LESSER DEGREE.
AGAIN THE DIFFERENCES IN TERMS
OF PERCENTAGE POINT IS
RELATIVELY MODEST.
HERE WE SEE A SMALL DIFFERENCE
IN STATES WITH THE HIGHEST
TELEMEDICINE GROUP SEEING MORE
PATIENT FROM A DIFFERENT STATE.
WE'LL SHOW THE SAME RESULT.
COMPARED TO 2018 AND THE LOW
TELEMEDICINE GROUPS WE'RE
SHOWING THE RELATIVE CHANGE OVER
TIME.
IF YOU CAN FOCUS JUST ON THE
CYAN OR TURQUOISE IS THE HIGHEST
TELEMEDICINE GROUP.
IN 2023 WE DON'T SEE SUBSTANTIVE
DIFFERENCES.
A SMALL DIFFERENCE IN TERMS OF
RURAL.
A MORE SUBSTANTIAL DIFFERENCE IN
A FRACTION OF PATIENTS COMING
FROM 20 MILES PLUS.
IS THIS CONTINUITY OF CARE OR
REFLECT NEW PATIENTS COMING IN?
WE CONTROLLED FOR THAT BY
KEEPING PATIENTS' LOCATION FIXED
AND ROUGHLY HALF THE DIFFERENCE
GOES AWAY AFTER WE CONTROL FOR
LOCATION.
THE WAY WE INTERPRET THAT IS
HALF THE INCREASE IN PATIENTS
COMING FROM FAR AWAY IS DRIVEN
BY YOUR EXISTING PATIENTS MOVING
VERSUS NEW PATIENTS ENTERING THE
PANEL.
AND I MENTIONED WE'LL LOOK AT
NEW PATIENTS ACROSS THE
DIFFERENT QUARTILES AT BASELINE.
THE HIGH TELEMEDICINE GROUP IS
SEEN SEEING FEWER NEW PATIENTS
AND ACROSS ALL GROUPS WE SEE
LESS NEW PATIENTS.
SO SUMMARY OF OUR FINDINGS,
TELEMEDICINE ADOPTION
UNFORTUNATELY ONLY LED TO A
SMALL OR NO GEOGRAPHIC REACH
AND A SMALL FRACTION IS PATIENTS
ENTERING THE PANEL AND AFTER THE
START OF THE PANDEMIC WE SEE A
DECREASE IN PATIENT SLOTS.
TO END IF YOU CAN CLICK THROUGH
ONCE, WHY DIDN'T MY VISION AND
DR. OZ'S VISION, SO MANY
PEOPLE'S HOPE TO TRY TO USE
TELEMEDICINE TO EXPAND ACCESS?
SOME IS DRIVEN BY WHICH
CLINICIANS HAVE EMBRACED
TELEMEDICINE, MORE URBAN
CLINICIANS AND CLINICIANS AND
MENTAL HEALTH SPECIALISTS HAVE
BEEN OVERWHELMED BY DEMAND OF
THE MENTAL HEALTH CRISIS SO IN
THAT CONTEXT IT'S NOT SURPRISING
THEY PREFERENTIALLY SOUGHT OUT
PATIENTS AND THOSE ARE LEAST
LIKELY TO USE TELEMEDICINE.
WHERE DO WE DO FROM HERE?
THE EXPECTATION IS WE OFFER
TELEMEDICINE AND ALL OF A SUDDEN
THEY'LL START OFFERING CARE WILL
NOT HAPPEN WE NEED TO CREATE
INCENTIVES AND POTENTIALLY
CHANGE REFERRAL NETWORKS AND
MAKE SURE THOSE PATIENTS IN
RURAL COMMUNITIES CAN GET INTO
THE URBAN AREAS AND WE NEED TO
MAKE SURE OUR RURAL PATIENTS CAN
ACCESS TELEMEDICINE.
I'LL END BY THANKING THE NIH AND
FOR FUNDING AND EXCITED TO TAKE
QUESTIONS.
>> GREAT, THANK YOU,
DR. MEHROTRA.
WE'LL BEGIN THE Q&A SECTION NOW.
WE HAVE A LITTLE BIT OF TIME.
THIS IS A QUESTION FOR ALL THE
PANELISTS, WHAT IF ANY ELEMENTS
HAVE BEEN IDENTIFIED TO BE
NECESSARY CONDITIONS TO
IMPLEMENT AND SUSTAIN INTEGRATED
TREATMENT?
WHO WOULD LIKE TO START?
WOULD ANYBODY LIKE TO START?
>> WHAT WE'VE SEEN WITH
TELEMEDICINE IS THERE'S
VARIATION IN HOW SUSTAIN THE
TELEMEDICINE USE HAS BEEN IN
MENTAL HEALTH CONDITIONS IT'S
BEEN MORE SUSTAINED THAN FOR
CARDIOLOGY AND HAVING A VIDEO
VISIT IS INEFFICIENT IN MANY
CIRCUMSTANCES AND WE NEED THE
TECHNOLOGY NECESSARY TO SUSTAIN
AND HOW DO YOU PROVIDE A
PHYSICAL EXAMPLE.
THAT'S AN EXAMPLE OF ONE THING
THAT CAN SUSTAIN THE USE.
>> IN TERMS OF ESSENTIAL
TREATMENTS OF INTEGRATED CARE IS
THE IDEA OF COLLABORATION AND
COMMUNICATION BOTH WITHIN AND
EXTERNAL TO A CLINIC.
SO IF YOU ARE IN A HEALTH CARE
ENVIRONMENT AND HAVE A TEAM,
HAVING THAT COLLABORATION
DEDICATED TIME POTENTIALLY FOR
HUDDLING IT WILL BE IMPORTANT TO
DRIVE THE INTEGRATIVE CARE.
IF YOU'RE INTEGRATING WITH LIKE
AN SUD SPECIALIST AND YOU'RE A
PRIMARY CARE PROVIDER HAVING
ROUTINE COMMUNICATION, EASE AND
HAVING THAT TEAM IS SNRNL.
-- ESSENTIAL.
>> DR. MEARA.
>> IN THE CONTEXT OF OUR WORK
FOCUSES ON THE ACO
ORGANIZATIONS, THE THINGS THAT
COME UP WHEN YOU SEE PLACES
ADOPTING ARE THIS TENDENCY TO
HAVE CONTRACTS IN MEDICAID AND
SEEING PATIENTS WITH HIGHER NEED
AND THEY HAVE HIGHER PROPORTIONS
ARE DUAL ELIGIBLE FOR MEDICATE,
HIGHER PROPORTION TO HAVE THESE
CONDITIONS AND THEN AS YYOU SAWA
LOT OF TIMES IT'S HAVING
SPECIALTY MENTAL HEALTH OR
SUBSTANCE USE PROVIDERS IN YOUR
NETWORK.
SOMETIMES YOU NEED A CHAMPION TO
GET THESE THINGS GOING.
THOSE ARE THE PATTERNS WE SEE.
>> THANK YOU.
DR. GORDON, I HAVE A QUESTION I
CAN START WITH YOU.
ARE YOU AWARE OF ANY WORK ON
INTEGRATING CARE FOR BEHAVIORAL
ADDICTIONS GAMBLING OR OTHER
ADDICTIVE BEHAVIORS?
>> IN THE HEALTH CARE SYSTEMS I
WORK IN IT'S BEEN LESS OF A
FOCUS.
USUALLY BEHAVIORAL ADDICTIONS IS
A LITTLE BIT MORE APART FROM THE
MEDICAL MODEL ASSOCIATED WITH
OPIOID USE DISORDER OR CAN BE
DONE WITHIN THE CONFINES OF
MEDICATION OR PHARMACO
THERAPIES, ETCETERA.
AGAIN, HAVING THAT GOOD LINKAGE
BETWEEN SPECIALTY CARE PROVIDER
AND PRIMARY CARE PROVIDER IS
GOING TO BE REALLY IMPORTANT IN
COMMUNICATION.
OFTEN TIMES IN THE REAL WORLD
SETTINGS WE HAVE NOTES FOR
SPECIALISTS OR SHARE MEDICAL
INFORMATION BUT SOMETIMES OFF
KEY CONVERSATIONS AND
COMMUNICATIONS CAN REALLY HELP
THAT INTEGRATION.
PARTICULARLY AREAS OF BEHAVIORAL
ADDICTION THAT CAN BE
DELETERIOUS FOR THE PATIENT AND
MAKING SURE THE PRIMARY CARE
PROVIDER OR SPECIALIST
UNDERSTAND THE CONTEXT OF THAT
ADDICT
ADDICTION.
WE'RE NOT TRAINED IN GENERAL
MEDICAL CARE.
SO SOMETIMES THAT CONSULTATION
AND COMMUNICATION AND AD HOC
COMMUNICATIONS ARE IMPORTANT TO
SYNERGIZE THAT CARE.
>> I APPRECIATE IT.
THANKS SO MUCH.
I THINK WE HAVE TIME FOR ONE
MORE QUESTION.
THERE'S AN INTERESTING APPROACH
TO LOOK AT THE QUARTILES AND
WHAT MOTIVATED THE USE OTHER
THAN GROUPS LIKE THREE, YEAR,
FIVE.
>> A GREAT METHODS QUESTION.
WHEN WE DID THIS BREAK DOWN WE
DID IT ARBITRARILY.
RESEARCHERS DO IT FIVE DIFFERENT
WAYS AND SENSITIVITY ANALYSES
AND THE RESULTS ARE ROBUST TO
THE DIFFERENT METHODS.
WE DID PRE SPECIFIED CUT OFFS
AND USING QUINTILES, TERTILES.
AND NO DIFFERENCE WE OBSERVED.
>> MAYBE TIME FOR ONE MORE.
MAYBE TO THE LARGER GROUP IF
ANYONE CAN SPEAK A LITTLE BIT
ABOUT WHETHER -- I THINK MY TIME
IS DONE.
THANK YOU ALL SO VERY MUCH.
>> WE HAVE A BREAK UNTIL 2:20
AND WE'LL RECONVENE TO TALK
ABOUT ENGAGING PATIENTS AND
FAMILIES WITH LIVED EXPERIENCE.
THANK YOU.
WELCOME BACK, EVERYONE FROM
THE BREAK.
WE'RE THRILLED TO INTRODUCE OUR
NEXT SESSION EXPERIENCE OF LIVED
EXPERIENCE AND FEEL FREE FREE TO
TAKE IT AWAY.
>> GOOD AFTERNOON, EVERYONE.
WELCOME TO OUR PANEL ON
EXPERIENCES OF PERSONS WITH
LIVED EXPERIENCE AND FAMILIES.
I'LL BE FACILITATING THIS PANEL
ALONG WITH KELLY DAVIS WHO WILL
PASS IT ON TO BEFORE INTRODUCING
OUR SPEAKERS.
>> THANKS SO MUCH.
HI, EVERYONE.
I'M VERY EXCITED TO BE HERE.
AS A PERSON WITH LIVED
EXPERIENCE I'VE PERSONALLY SEEN
IN OUR WORK AND IN MY
PARTICIPATION IN RESEARCH THE
DIFFERENCE LIVED EXPERIENCE CAN
MAKE IN FIGURING OUT WHAT THE
PROBLEM IS AND WHAT WE SHOULD DO
ABOUT IT AND WHAT'S IMPORTANT
OUTCOMES FOR FOLKS.
WE'LL HEAR SOME REALLY POWERFUL
EXAMPLES TODAY AND I'M EXCITED
TO ALSO HAVE A DISCUSSION ONCE
EVERYONE'S MIC'D UP.
>> THANK YOU, KELLY.
I WILL INTRODUCE OUR FIRST
SPEAKER.
SO DR. ASHLI SHEIDOW IS AT
CHESTNUT HEALTH SYSTEMS IN
SERVICES FOR TEENS AND YOUNG
ADULTS.
PARTICULARLY THOSE WITH
SUBSTANCE USE PROBLEMS.
HER TALK IS ON ENGAGING
INDIVIDUALS WITH LIVED
EXPERIENCE.
>> THANK YOU SO MUCH.
I'D LIKE TO START BY SAYING I'VE
HAD EXPERIENCE IN MULTIPLE
GENERATIONS BUT COMING FROM A
RESEARCHER PERSPECTIVE FOR
ENGAGEMENT FOR THOSE WHO USE THE
TERM AND I LIKE THE WAY KELLY
PUT IT AS WHAT CAN BE LEARNED
AND THE VALUE.
IT'S NOT ROCKET SCIENCE BUT WE
AS RESEARCHERS HAVEN'T DONE THIS
WELL.
IN MY CAREER, I HAVE ALWAYS DONE
WHAT I CALL REAL WORLD RESEARCH,
MEANING, IT WAS OUT IN THE
COMMUNITY RATHER THAN IN THE
IVORY TOWER OF ACADEMIA.
IN THE LAST YEARS I'VE BEEN IN
PARTICIPATORY BASED RESEARCH AND
CHANGED MY RESEARCH AND HOPE I
CAN CONVINCE YOU TO SHIFT THE
WAY YOU DO ECONOMICS RESEARCH.
I FULLY UNDERSTANDING THE WAY
YOU DO RESEARCH MAY NOT BE
FEASIBLE BUT PLEASE KNOW NO
MATTER TO WHAT EXTENT YOU CAN
SHIFT EVERY BIT CAN HELP.
AND SKIM OVER IN THE INTEREST OF
TIME BUT COME BACK TO THINGS IN
THE Q&A OR REACH OUT.
MY E-MAIL ADDRESS IS AT THE END
OF THE SLIDES.
A HEARTFELT THANK YOU TO THE TO
COMMUNITY MEMBERS AND STAFF AND
COLLEAGUES WHO I'VE WORKED WITH
AND PARTNERED WITH ME AND TAUGHT
ME A LOT OVER THE YEARS.
I WANT TO LET YOU KNOW MY TEAM
HAS COLLECTED TOOLS AND
RESOURCES ABOUT
COMMUNITY-ENGAGED RESEARCH AT
THE WEBSITE LISTED HERE AND YOU
CAN ACCESS IT THROUGH THE QR
CODE.
THIS INCLUDES A HOW-TO TOOL KIT
FOR PEOPLE WITH SUBSTANCE USE
AND SOME ITEMS I'LL COVER COME
FROM THAT RESOURCE AND THANK YOU
TO NIDA AND NIH FOR THE FUNDING
ON THE WORK I'LL PRESENT.
HERE'S A FAST OVERVIEW OF THE
LIVED EXPERIENCE PANEL AND THE
COMMUNITY BOARDS.
I'LL SHARE SOME EXAMPLES FROM
THE PROJECTS AND ALSO QUOTES
FROM MEMBERS WHO HAVE GIVEN ME
PERMISSION IN HEAL CONNECTION I
LED COMMUNITY-BASED
PARTICIPATORY RESEARCH WHERE WE
ENGAGED A LIVED EXPERIENCE
PANEL.
THIS WAS A NATIONWIDE PANEL
WHERE WE ENGAGED A 55 MEMBER
PANEL COMPRISED OF 11 SUB PANELS
FOR COMMUNITIES WITH HEALTH
DISPARITIES LISTED ON THE SLIDE.
EACH SUB PANEL FOCUSSED ON
CHALLENGES AND DISSEMINATION
CHANNELS THAT CLOSE THE SCIENCE
TO SERVICE GAP WITHIN THEIR
RESPECTIVE COMMUNITY.
OTHER EXAMPLES TODAY WILL COME
FROM THE SUPPORT OF RECOVERY
SERVICES FOR JUSTICE INVOLVED OR
EMERGING ADULT POPULATIONS.
JEAP HAS TWO BOARDS AND SOME ARE
PEOPLE WITH LIVED EXPERIENCE.
TODAY THE COMMUNITY BOARDS GUIDE
THE BROADER WORK OF THE JEAP
ENGAGEMENT.
FOR HEAL CONNECTIONS LOOKING AT
SPECIFIC BARRIERS TO CARE RATHER
THAN ACROSS ALL THE HEALTH
DISPARITY POPULATIONS.
THIS CAN ENSURE THEY REFLECT
REAL WORLD INEQUITIES.
WHAT SHOULD WE EVEN BE
RESEARCHING IN THE FIRST PLACE?
FROM EVEN THAT LEVEL TO IDENTIFY
THE REAL WORLD INEQUITIES.
THE PANELS ALSO LEAD TO
CENTERING PEER SUPPORT,
COMMUNITY CONTEXT AND
DISSEMINATION EQUITY AND ALSO
SURFACED CONTEXT SPECIFIC
CHALLENGES.
SO FOR EXAMPLE THE SUB PANEL ON
CO-OCCURRING OPIOID USE DISORDER
AND MENTAL HEALTH DISORDERS
EMPHASIZED TRAUMA INFORMED CARE
AND MENTAL HEALTH PARODY WHILE
THE PREGNANCY LOOKED AT LEGAL
CONCERNS IN THE PROVIDER
INTERACTIONS.
BROADLY I THINK OF LEARNING
THINGS YOU'VE NEVER LEARNED
BEFORE AND ALSO YOU HAVE GREATER
REAL WORLD IMPACT AND MAKE IT
LESS LIKELY YOUR RESEARCH
FINDINGS WILL NOT BE WANTED BY
THE COMMUNITY YOU'RE TRYING TO
HELP.
YOU CAN GET INSIGHT AND
SOLUTIONS YOU CAN'T GET ON YOUR
OWN OR FROM YOUR TEAM AND DIRECT
BENEFITS FROM THE RESEARCHERS
BEYOND THE MUTUAL LEARNING AND
IMPROVED INTELLECTUAL HUMILITY
IT CAN BE SEEN AS A PATH TO MORE
EQUITABLE RESEARCH OUTCOMES.
SO COMMUNITY ENGAGED RESEARCH
HAS BENEFITS FOR THE IMPACTED
COMMUNITY MEMBERS.
ONE MEMBER POIGNANTLY PUT IT TO
ME AS GIVING VOICE TO THE
VOICELESS BUT BE AWARE OF
POTENTIAL HARMS TO COMMUNITY
MEMBERS PARTICULARLY BECAUSE
SUBSTANCE USE AND MENTAL HEALTH
CARRIES SO MUCH STIGMA IN OUR
SOCIETY.
BE PREPARED TO AVOID THINGS
TOKENISM AND LOSS OF TRUST WHEN
PROVIDERS ENGAGE IN HURTFUL
BEHAVIOR SOMETIMES UNKNOWINGLY
BUT IT'S THE IMPACT THAT COUNTS.
THERE'S GUARDRAILS IN OUR TOOL
KIT BASED ON WHAT OUR PARTNERS
TAUGHT US AND SKILLS TO HONE AND
THE QUOTE ABOUT GIVING PARTNERS
CONTROL OVER WHAT AND HOW THEY
SHARE.
AND THERE ARE A COUPLE QUOTES ON
THE NEXT SLIDE RELATED AND YOU
CAN LEARN IT FROM THE BOARD AND
PANEL MEMBERS RATHER THAN FROM
ME.
AND EMPHASIZE THINKING HOW TO
ENGAGE MEMBERS FROM THE START OF
THE SELECTION PROCESS.
SHE PUT IT AS INVITING SOMEONE
NORM DINNER AND MUGGING THEM AT
THE DOOR AND ADDITIONAL WAYS
BEYOND EQUITABLE COMPENSATION
WHICH IS CRITICAL BUT WAYS
BEYOND THAT FOR RESEARCHERS TO
SHOW THEY VALUE BOARD MEMBERS
AND IF YOU CAN'T DIGEST ANY
QUOTES QUICKLY ENOUGH I'M HAPPY
TO SHARE MY SLIDES WITH YOU.
NOW, COMMUNITY IDENTIFIED
CHALLENGES AND THE BOARD ENGAGED
AT THE START OF THE JEAP
INITIATIVE TO DEVELOP RESEARCH
PRIORITIES.
THE PROCESS WE USED IS DETAILED
IN THE WEB PAGE THERE ON THE
SLIDE.
THESE RESEARCH PRIORITIES WERE
INTENDED TO PRIORITIZE RESEARCH
STUDIES AND SINCE DEVELOPED
THEY'VE BEEN UTILIZED IN
NUMEROUS GRANT APPLICATIONS AND
PILOT STUDIES AND REVIEW PAPERS.
THERE'S A BRAND NEW ONE THAT
JUST CAME OUT LAST NIGHT.
IN HEAL CONNECTION THEY
IDENTIFIED WHAT KEEPS THEM UP AT
NIGHT IN TREATMENT AND SERVICES
IN RESPECTIVE COMMUNITIES AND
THEY VARY WIDELY.
AGAIN, EMPHASIZING THE NEED FOR
TAILORED RESPONSES.
THESE ARE THOUGHTS ON ENGAGING
PEOPLE WITH LIVED EXPERIENCE AND
THROUGH HEALTH ECONOMICS
RESEARCH.
THESE WILL BE AVAILABLE IN MY
SLIDE.
I WON'T GO THROUGH EACH OF THEM.
WE CAN REVISIT THEM IN THE Q&A
SECTION.
FROM MY EXPERIENCE OF KNOWING
SOME ABOUT HEALTH ECONOMICS
RESEARCH BEING A CONSUMER AND
FROM THE OTHER SIDE OF WORKING
CLOSELY WITH PEOPLE WITH LIVED
EXPERIENCE.
BEFORE I CONCLUDE AND MAKE CLEAR
GENUINE COMMUNITY ENGAGE
RESEARCH IS DIFFICULT AND IT
LIKELY FOREIGN TO MORE
TRADITIONAL RESEARCHERS.
IT REQUIRES MORE WORK AND
INVESTMENT THAN TRADITIONAL
RESEARCH AND AS WELL AS A HIGH
DEGREE OF INTELLECTUAL HUMILITY.
THAT SAID, MY EXPERIENCE HAS
DEMONSTRATED FOR ME AT LEAST,
ENGAGEMENT ISN'T OPTIONAL OR
COMPLIMENTARY, IT'S ESSENTIAL.
I BELIEVE IF WE ARE TO MAKE A
DIFFERENCE, RESEARCH MUST BE
TAILORED TO REAL WORLD CONTEXT
AND BARRIERS.
SECONDLY, I BELIEVE ENGAGEMENT
MUST BE ONGOING AND NOT
EXTRACTIVE.
THIS MEANS THROUGHOUT THE
PROJECT LIFE CYCLES AND WITH A
MEANINGFUL, MUTUAL BENEFIT FOCUS
AND THIRD PARTNERSHIP MUST BE
ACCESS IN AND CO-OWNED.
SO MAKE SURE TO EVALUATE
YOURSELF AND THE ENGAGEMENT THAT
YOU'RE TRYING TO BUILD.
MID COURSE CORRECT IF YOU NEED
TO AND HAVE THAT HUMILITY IN
WORKING WITH PEOPLE WITH LIVED
EXPERIENCE TO BE THE EXPERTS AND
GIVE YOU GUIDANCE HOW TO
CONSTANTLY IMPROVE AND
CO-PRODUCTION AND I'LL LEAVE YOU
WITH A NUMBER ONE CALL TO ACTION
AND ONE I LIKE TO SQUEEZE IN
WHENEVER I CAN.
FIRST AS RESEARCHERS, FUND AND
POLICY MAKERS WE MUST MATCH
RECIPROCAL PARTNERSHIP TO LIFT
LIVED EXPERIENCE AS EXPERTISE
AROUND STRIVE TO OVERCOME
BARRIERS TO WORK WITHIN THE
ENTIRE RESEARCH ENTERPRISE.
SO NOT JUST AS INDIVIDUALS THAT
ARE ON COMMUNITY BOARDS AND
GUIDING OUR WORK, BUT ACTUALLY
AS PEOPLE AS STAFF AND WORKING
WITHIN THE RESEARCH ENTERPRISE
INCLUDING AS LEADERS OF FUTURE
RESEARCH.
SO THAT I HAVE MY E-MAIL ADDRESS
AND ALL YOU'RE DOING TO IMPROVE
RESEARCH AND OUTCOME AND LET ME
KNOW IF I CAN BE HELPFUL.
>> THANK YOU SO MUCH.
I THINK THIS WAS AN AMAZING
PRESENTATION, DR. SHEIDOW.
I APPRECIATE YOUR CALL FOR
ACTION.
SO PLEASE EVERYONE, IF YOU HAVE
ANY QUESTIONS, POST THEM IN THE
Q&A BOX AND WE'LL LEAVE THE Q&A
TO THE END OF THE PANEL.
SO LET'S ME OF ON TO OUR NEXT
PRESENTER, DR. KIMBERLY GEISSLER
WHO IS ASSOCIATE PROFESSOR AND
CHIEF OF THE DIVISION OF HEALTH
EQUITY AND HEALTH SERVICES
RESEARCH BASED AT BAY STATE
HEALTH AND HER TALK IS ON THE
EFFECT OF MEDICAID ACCOUNTABLE
CARE ORGANIZATIONS ON BEHAVIORAL
HEALTH CARE QUALITY AND OUTCOMES
FOR CHILDREN.
SHE IS A HEALTH ECONOMIST AND
HAS DONE GREAT WORK IN HEALTH
POLICY RESEARCH AND HEALTH CARE
FOR VULNERABLE POPULATIONS.
I'LL PASS IT TO HER.
THANK YOU SO MUCH.
>> GREAT YOU, THANK YOU SO MUCH
FOR INVITING ME AND HOSTING THIS
TODAY.
THIS IS RELATIVELY NEW WORK AND
WE'RE ONE AND A HALF YEARS INTO
A FIVE-YEAR PROJECT.
I'LL SHOW YOU SOME OF THE
RESULTS AS WE GO ALONG.
PEDIATRIC MENTAL HEALTH ARE OF
SERIOUS CONCERN.
1 IN 4 CHILDREN EXPERIENCE
BEHAVIORAL HEALTH DISORDERS IN
THE U.S.
THE MOST COMMON ADHD, ANXIETY
AND DEPRESSION.
MORBIDITY AND MORTALITY DUE TO
BEHAVIORAL HEALTH DISORDERS IS
HIGH WITH SUICIDE AS THE LEADING
CAUSE OF ADOLESCENT DEATH.
THERE'S SUBSTANTIAL BARRIERS
ARRIVING AT MULTIPLE LEVELS,
POLICY, COMMUNITY, HEALTH SYSTEM
AND PROVIDERS.
THE BARRIERS TO CARE
PARTICULARLY AFFECT LOWER INCOME
AND MINORITIZED POPULATIONS.
ONE WAY TO ADDRESS THIS IS
MEDICAID.
ALMOST 40% OF CHILDREN IN THE
UNITED STATES ARE ENSURED BY
MEDICAID OR BY THEIR CHILDREN'S
HEALTH INSURANCE PROGRAM.
MEDICAID AS YOU PROBABLY KNOW IS
A STATE FEDERAL PARTNERSHIP
PROVIDING INSURANCE TO
LOW-INCOME OR DISABLED
INDIVIDUALS.
THOUGH ELIGIBILITY AND BENEFITS
VARY BY STATE, MORE THAN HALF OF
CHILDREN FROM MINORITIZED ETHNIC
AND RACIAL GROUPS ARE COVERED BY
MEDICAID.
ONE WAY THEY'RE ADDRESSING
HEALTH CARE IS THROUGH
ACCOUNTABLE CARE ORGANIZATIONS.
THE ACCOUNTABLE CARE
ORGANIZATIONS, THERE ARE
VALUE-BASED PAYMENT MODEL THAT
CENTERED AROUND PRIMARY CARE
PRACTICES.
SO IN AN ACO, A GROUP OF
CLINICIANS, GENERALLY PRIMARY
CARE CLINICIANS PROVIDES CARE
FOR A SPECIFIED SET OF PATIENTS
AND THEN HAS RESPONSIBILITY FOR
THE QUALITY AND COST OF CARE FOR
THOSE PATIENTS.
MOST OF THESE ACO ARE UNDER
SECTION 1115 WAIVERS WHICH CAN
BE USED TO IMPROVE MEDICAID
PROGRAMS.
BETWEEN 2016 AND 2023, 21 STATES
HAD MEDICAID ACOs AT SOME POINT.
AND 11 STATES HAD ACTIVE
MEDICAID ACOs IN 2023.
MASSACHUSETTS IMPLEMENTED
MEDICAID ACOS AND LAUNCHED THEM
IN MARCH OF 2018.
AND CHILDREN WERE MOVED INTO THE
ACOs BASED ON THEIR PCP
PRACTICE.
THIS IS A QUASI-EXPERIMENTAL
DESIGN BECAUSE WE HAVE THIS
ASSIGNMENT THAT HAPPENS WITHOUT
ACTION TAKEN BY THE PERSON.
THERE WERE 16 ACOs AND THERE ARE
SUBSTANTIAL ORGANIZATIONAL
CHANGES AND PATIENT AND OTHER
CHARACTERISTICS.
IT WAS A HUGE TRANSFORMATION OF
THE CARE DELIVERY SYSTEM.
SO STATEWIDE MORE THAN 90% OF
CHILDREN MOVED TO THE ACOs
WITHIN A YEAR AND THIS WAS 80%
OF ALL MEDICAID ENROLLEES.
THIS WAS A HUGE CHANGE TO THE
DELIVERY SYSTEM IN
MASSACHUSETTS.
THINKING COULD THESE MEDICAID
ACOs BE A WAY TO REDUCE
DISPARITIES IN BEHAVIORAL HEALTH
CARE IN CHILDREN.
THEY COULD POTENTIALLY IMPROVE
CARE THROUGH SHARED RISK
CONTRACTS, INCREASEDIN
SENSITIVES AND INCREASED
MEASURES OF SOCIAL DETERMINATES
OF HEALTH AND CARE MANAGEMENT
AND INTEGRATIVE BEHAVIORAL
HEALTH THAT MAY BE MORE
DIFFICULT IN A FEE FOR SERVICE
SYSTEM.
OUR OVER ALL STUDY IS USING A
MIXED METHODS APPROACH TO STUDY
THE AFFECT OF THE IMPLEMENTATION
ON BEHAVIORAL HEALTH OUTCOMES
AND DISPARITIES IN CHILDREN WHO
USE MENTAL HEALTH CARE.
AIM 1 IS LOOKING AT THE IMPACT
FOR MEDICARE INSURED CHILDREN
AND DESPAIRS FOR MEDICAID VERSUS
PRIVATELY INSURED CHILDREN AND
CHOOSING HOW HETTER GEN AITY
AFFECTS OUTCOMES AND
ORGANIZATIONAL FEATURES MEDICAID
ACOs.
WE HAVE A HUGE AMOUNT OF DATA
AND PARTICIPANTS ACROSS THE
STUDIES.
WE'RE USING ALL PAIR CLAIMS DATA
AND NATIONAL DATA TO LOOK AT
CLAIMS-BASED UTILIZATION AND
OUTCOMES.
WE HAVE CONDUCTED A SURVEY OF
ACO LEADERSHIP.
THIS WILL HELP US UNDERSTAND
ORGANIZATIONAL CHARACTERISTICS
OF EACH ACO TO UNDERSTAND WHO
THEY'RE TREATING, WHAT KIND OF
EXPERIENCE THEY HAVE WITH
CONTRACT AND HEALTH CARE.
AND WE ARE INTERVIEWING THREE
SETS OF INFORMANTS.
WE'LL INCLUDE ACO LEADERSHIP TO
TELL US MORE ABOUT STRUCTURAL
CHANGES WITHIN THE ACOs,
PROVIDERS TO REALLY TELL US HOW
THESE CHANGES HAVE BEEN
IMPLEMENTED ON THE GROUND AND
PARENTS TO PROVIDE INFORMATION
ABOUT THEIR EXPERIENCE WITH
THEIR CHILD'S BEHAVIORAL HEALTH
CARE.
AND WE'RE ALSO USING THE
NATIONAL SURVEY OF CHILDREN'S
HEALTH AND THIS WILL ALLOW US TO
EXAMINE THINGS THAT ARE MORE
PATIENT REPORTED.
WE ALSO HAVE A COMMUNITY
ADVISORY BOARD AND IT HAS
PARTICIPANTS FROM NATIONAL
POLICY MAKERS AND LOCAL
REPRESENTATIVES FROM BEHAVIORAL
HEALTH CARE SYSTEMS WITHIN THE
STATE AND THEN REPRESENTATIVE
FROM A PATIENT ADVOCACY GROUP.
SO WE'RE LOOKING AT THE
RELATIONSHIP BETWEEN PATIENT
REPORTED EXPERIENCE AND
ORGANIZATIONAL FEATURES OF
MEDICAID ACOs.
ANCE WE'RE USING THE NATIONAL
SURVEY OF CHILDREN'S HEALTH AND
HERE WE'RE ABLE TO EXAMINE UNMET
NEED, PARENT-REPORTED EXPERIENCE
AND COORDINATION OF CARE.
AND HAD PLANNED TO USE A SURVEY
CONDUCTED WITH CHILDREN ONLY IN
MASSACHUSETTS BUT WE WEREN'T
ABLE TO OBTAIN THE DATA AND
MOVED TO A DIFFERENT DATA SOURCE
THAT WILL ALLOW US TO ACHIEVE
THE GOALS.
WE'RE CONDUCTING INTERVIEWS WITH
PARENTS ACROSS THE STATE AND
WITH A RANGE OF EXPERIENCES AND
SEVERITY OF THEIR CHILD'S MENTAL
ILLNESS AND THEN CONDUCTING THE
SURVEYS, LEADERSHIP INTERVIEWS
AND PROVIDER INTERVIEWS.
WE'RE FINDING LIMIT ED CHANGES
AND UNMET NEED AND OTHER
PARENT-REPORTED SURVEY OUTCOMES
RELATED TO MEDICAID ACO
IMPLEMENTATION.
WE FIND WELL AWARENESS OF
PARENTS WITH CHILDREN WITH
BEHAVIORAL HEALTH SYSTEM AND
ONGOING LOCAL AND STATE
INITIATIVES MAKES IDENTIFYING
CHANGES RELATED TO ACO'S
CHALLENGING FROM A POLICY
PERSPECTIVE.
A RECENT EXAMPLE OF
INCORPORATING LIVED EXPERIENCE
IS THAT WE CONDUCTED ALL THESE
CLAIMS BASED ANALYSES AND NEED
TO INTERPRET THE FINDINGS.
SO WE NEED TO DETERMINE IS THE
FINDING OF DECREASED VISITS FOR
CHILDREN WITH BEHAVIORAL HEALTH
CONDITIONS DUE TO ACCESS TO CARE
OR DUE TO IMPROVED COMMUNICATION
AND OTHER SETTINGS?
THIS IS SOMETHING YOU CANNOT
TELL FROM CLAIMS DATA AND
COMBINING IT WITH SURVEY DATA
AND EXAMINING UNMET NEED AND
PARENT INTERVIEWS FOR A MORE
HOLISTIC INTERPRETATION OF
CHANGES AND OVER USE AND
APPROPRIATE USE OF SERVICES IS
COMMONLY MENTIONED.
WE'LL DO ADDITIONAL ANALYSES TO
FIND DIFFERENT SETS OF SERVICES
THAN ORIGINALLY PLANNED.
AND THINKING ABOUT THE LIVED
EXPERIENCE, PARENTS OFTEN DON'T
OBSERVE THE BEHIND THE SCENES
CHANGES AND NEED TO IN CORP RATE
MULTIPLE LEVELS AND DEDICATING
EXPERTISE, TIME AND RESOURCE TO
INCORPORATING THE LIVED
EXPERIENCE IS CRITICAL TO
ADVANCE THE SCIENCE.
THIS IS MY CONTACT INFORMATION
AND THANK YOU AGAIN TO NIH FOR
FUNDING THIS STUDY.
>> THANKS SO MUCH.
I'M GOING TO TURN IT TO OUR NEXT
PANELIST.
EXCITED TO HEAR FROM DR. LAURA
CHAVEZ FROM NATIONWIDE
CHILDREN'S.
>> THANK YOU FOR ALLOWING ME TO
SHARE OUR WORK.
I WANT TO BEGIN WITH
ACKNOWLEDGING FUNDING FOR THIS
WORK FROM NIMHD AND ALSO WILL BE
PRESENTING PART OF A PROJECT
USING A PEDIATRIC ACCOUNTABLE
DATA FROM CHILDREN'S NATIONWIDE
AND I HAVE SOME DISCLOSURES
ABOUT THE DATA AND OF COURSE I
WANT TO ACKNOWLEDGE
CO-INVESTIGATORS ON THE PROJECT
AS WELL AS ANALYSTS.
FIRST, A BIT OF BACKGROUND.
I WANTED TO SHOW TRENDS IN
POVERTY SINCE 2009 IN THE UNITED
STATES FOR CHILDREN.
WHICH IS MEASURED WITH TWO
DIFFERENT MEASURES.
THE OFFICIAL MEASURE IN RED AND
SUPPLEMENTAL POVERTY MEASURE IN
BLUE.
THE OFFICIAL MEASURE IS BASED ON
TAXABLE INCOME USED TO DETERMINE
ELIGIBILITY FOR BENEFITS AND THE
SUPPLEMENTAL POVERTY MEASURE WAS
CREATED WITH THE INTENTION OF
OFFERING A CLEARER PICTURE OF
THE CONDITIONS OF POVERTY THAT
TAKE INTO ACCOUNT SOCIAL
PROGRAMS THAT OFFSET FINANCIAL
HARDSHIPS.
AND THEY'RE GENERALLY MOVING IN
PARALLEL.
YOU'LL SEE IN 2021 A
SUPPLEMENTAL POVERTY MEASURE DID
DIFFER FROM THE ORIGINAL MEASURE
AND REACHED A HISTORIC LOW OF
5.2%.
THIS WITH US LARGELY DUE TO
POLICY IT CHANGES THAT HAPPENED
IN 2021.
THE CHILD TAX CREDIT AND TO GIF
A BRIEF REFRESHER ON WHAT WAS
MEANINGFUL ABOUT THAT POLICY
CHANGE.
SO IT EXPANDED THE SIZE OF THE
CREDIT.
IT WAS NEARLY DOUBLE AND MADE
FULLY REFUNDABLE AND HALF THE
CREDIT WAS OFFERED TO FAMILIES
IN ADVANCE OF TAX FILING
DEPENDENT ON THE AGE OF THE
CHILD, $300 PER MONTH FOR EACH
CHILD UNDER 6 AND $250 A MONTH
FOR OLDER CHILDREN.
IT ALSO INCLUDED HOUSEHOLDS WITH
NO OR VERY LOW ECONOMIC THAT HAD
BEEN PREVIOUSLY INCLUDED FROM
THE CHILD TAX CREDIT.
AND IT'S REDUCING CHILD POVERTY
ON THE SUPPLEMENTAL POVERTY
MEASURE BY MORE THAN 30%.
WE ALSO SAW IN THIS TIME
RESEARCH HAS DEMONSTRATED
REDUCED FOOD INSECURITY AND
MATERIAL HARDSHIP AND ALSO IN
SOME STUDIES EVIDENCE OF MENTAL
HEALTH BENEFIT FOR ADULTS WITH
CHILDREN LIKE REDUCED DEPRESSION
AND ANXIETY.
WE'RE INTERESTED IN
UNDERSTANDING THE IMPACT ON
DLNLT TELEHEALTH AS WELL.
-- ADOLESCENT TELEHEALTH AS
WELL AND WE HYPOTHESIZED A
CHANGE IN INCOME REDUCTION IN
POVERTY COULD BENEFIT -- COULD
HAVE POSITIVE IMPACTS ON CHILD
MENTAL HEALTH.
ONE IS THROUGH THE INVESTMENT
PATHWAY.
THIS ADDITIONAL MONTHLY INCOME
COULD OFFER FAMILIES ADDITIONAL
RESOURCES THAT THEY CAN USE TO
INVEST IN PROMOTING RESOURCES
LIKE FOOD, HOUSING OR EVEN
OPPORTUNITIES TO SPEND MORE TIME
WITH CHILDREN.
AND THROUGH THE STRESS PATHWAY
THROUGH REDUCED FINANCIAL
DISTRESS FOR CAREGIVERS WE ALSO
ANTICIPATED POSITIVE MENTAL
HEALTH BENEFITS THERE.
THIS IS WHAT MOTIVATED OUR
PROJECT FUNDED BY NIMHD FOCUSSED
ON UNDERSTANDING THE CHANGES THE
POLICY HAD AND THE EFFECTS ON
BEHAVIORAL HEALTH FOR MEDICAID
AND ENROLLED ADOLESCENTS.
AND THIS IS PART THE LARGER
PROJECT THE MIXED METHODS
PROJECT AND SHOW SOME
QUANTITATIVE UNLESS WE DID
WITHIN OHIO THAT HAVE ADDITIONAL
QUALITATIVE FOCUSES WHILE WE
INTERVIEWED ADOLESCENTS ABOUT
THEIR EXPERIENCES.
I DON'T HAVE TIME TO SHARE BOTH
OF THOSE TODAY.
FOR OUR QUANTITATIVE ANALYSIS
I'LL SHOW YOU TODAY, I'LL FOCUS
ON OHIO.
IN OHIO PARTNERS FOR KIDS,
MEDICAID ACL, A SAMPLE OF 9,974
OLDER ADOLESCENTS AND TO TRY TO
UNDERSTAND WHAT WAS THE EFFECT
TO THE BEST EXTENT WE CAN ON
THIS FEDERAL POLICY ON OUTCOMES
WE COMPARED CHANGES IN TWO
DIFFERENT AGE GROUPS.
WE COMPARE AN AGE GROUP OF OLDER
ADOLESCENTS WHO HAVE NOD NOT
TURNED 18 WE THE END OF 2021 AND
THE FAMILY WOULD HAVE BEEN
ELIGIBLE TO RECEIVE THE PAYMENTS
COMPARED TO A SLIGHTLY OLDER AGE
GROUP THAT JUST AGED OUT AND
TURNED 18 BEFORE THE END OF
2021.
AND THE MEAN OUTCOME IS
PROBABILITY OF AN ACUTE HEALTH
CARE VISIT OR PATIENT SETTING
AND BASED ON THE MEDICAID CLAIMS
DATA AND HAVING A PRIMARY MENTAL
HEALTH DIAGNOSIS FOR THIS
ENCOUNTER OR ANY DIAGNOSIS OF
DELIBERATE SELF-HARM ON THE
ENCOUNTER.
AND TO GIVE YOU A BIT OF CONTEXT
ABOUT WHERE IN OHIO THIS IS
TAKING PLACE, WE'RE FOCUSSED ON
PARTNERS FOR KIDS WHICH IS A
MEDICAID ACL THAT COVERS OVER
3,000 MEDICAID INVOLVED
PEDIATRIC PATIENTS IN CENTRAL
AND SOUTHEASTERN OHIO.
THIS IS A GEOGRAPHICALLY DIVERSE
AREA OF THE STATE INCLUDING
RURAL AND URBAN AND LARGE NUMBER
OF COUNTIES WITH A PROPORTION OF
CHILDREN LIVING BELOW THE
POVERTY LINE.
IN THE DARKER SHADED COUNTIES
MORE THAN A QUARTER OF CHILDREN
LIVING BELOW THE POVERTY LINE.
SO IN OUR ANALYTIC APPROACH
WE'RE USING A DIFFERENCE
APPROACH.
WE'RE ASSUMING THAT BUT FOR THIS
ADDITIONAL CHILD BENEFIT FOR TWO
GROUPS OF SIMILARLY AGED
ADOLESCENTS, WE WOULD EXPECT TO
SEE THE SIMILAR OUTCOME
TRAJECTORIES.
WE'RE USING AN INTENT TO TREAT
APPROACH AND WE DON'T HAVE
INFORMATION ON WHETHER OR NOT
FAMILIES DID INDEED IN FACT
RECEIVE THE CHILD TAX CREDIT BUT
WE KNOW IN OUR STATE AND IN
OTHER STATES THE HIGH PROPORTION
OF FAMILIES DID RECEIVE THE
CHILD TAX CUT AND MONTHLY
PAYMENTS.
AND WE'RE ALSO USING HISTORICAL
DATA IN OUR MODELLING STRATEGY
TO ACCOUNT FOR SEASONALITY.
WHETHER THERE WERE DIFFERENCES
IN THE FIRST HALF TO THE SECOND
HALF OF THE YEAR IN ACUTE MENTAL
HEALTH CARE VIFLTS.
-- HEALTH CARE VISITS.
THIS IS OUR LOGISTIC REGRESSION
MODEL FOR BEHAVIORAL HEALTH
EVENT.
AND COMPLICATED BUT WE'RE
FOCUSSED ON THIS RED HIGHLIGHTED
INTERACTION TERM WHICH IS
ESSENTIALLY WE'RE LOOKING TO SEE
IF WE CAN DETECT A GREATER
DIFFERENCE BETWEEN THE TWO AGE
GROUPS IN 2021 WHEN THE CTC
POLICY WAS IN EFFECT AND WE
CONTROL FOR INDIVIDUAL
DEMOGRAPHIC CHARACTERISTICS AS
WELL AS FIXED EFFECTS.
HERE ARE SOME OF THE DESCRIPTIVE
DATA INCLUDING THE HISTORICAL
DATA PRIOR TO THE CTC POLICY
BEING INTRODUCED AS WELL AS 2021
WHEN THE POLICY INTO EFFECT AND
OUR TWO AGE GROUPS AND THE LAST
OF THE CTC INELIGIBLE GROUP THAT
TURNED 18 BEFORE THE END OF THE
CALENDAR YEAR AND THOSE WHO
TURNED 18 AFTER THE CALENDAR
YEAR.
IN THE HISTORICAL DATA WE SEE A
CONSISTENT OUTCOME OF AN ACUTE
EVENT AND ABOUT 2% OF OUR
SAMPLE.
THEN WE LOOK AT THE CHILD TAX
CREDIT YEAR THERE'S A SMALLER
SAMPLE BECAUSE WARE ONLY USING
ONE YEAR OF DATA IN THIS GROUP.
THE YEAR WHEN THE POLICY WENT
INTO AFFECT BUT WE SEE A SIMILAR
PERCENT OF THE SAMPLE WITH THE
EVENTS.
IN THE FAR RIGHT COLUMN YOU SEE
A HINT OF A POSSIBLE GREATER
DECREASE FOR THE ELIGIBLE
ADOLESCENTS.
SO DECREASE FROM BEFORE THE
POLICY WENT INTO AFFECT OF 2.5%
TO 1.8%.
AND HERE ARE OUR COEFFICIENT FOR
INTERACTION TERM AND WE SEE IN
THE OVER ALL TOTAL SAMPLE
SIGNIFICANT ODDS RATIO BELOW 1
AND SEE A SIGNIFICANT
INTERACTION IN OUR SUB GROUP OF
MALES BUT NOT FOR FEMALES.
WE HAD ALSO LOOKED AT THE BEFORE
THE POLICY WENT INTO AFFECT AND
TRENDS WERE PARALLEL OR
DIFFERENCE OR LEADING UP TO WHEN
THE POLICY WENT INTO AFFECT
ALREADY FOR THE TWO GROUPS.
SO WE WEREN'T SEEING ODDS RATIOS
THAT WE WE'RE SEEING THEY
INCLUDED ONE LEADING UP TO THE
POLICY.
SO NOT SEEING STRONG EVIDENCE
THIS WAS ALREADY A TREND.
IN SUMMARY WE SAW A DECREASE BUT
NOT SIGNIFICANT FOR FEMALE
ADOLESCENTS.
SO OUR RESULTS WE REPEATED OUR
RESULTS TO EXAMINE THE
ROBUSTNESS OF OUR FINDINGS USING
DIFFERENT MODELLING APPROACHES
AS WELL AS USING ADOLESCENTS
BORN IN THE MONTHS OF DECEMBER
OR JANUARY AS WELL AS EXPLORE
USING DISCRETION DISCONTINUITY
AS AN ADDITIONAL ANALYTIC
APPROACH.
SO IN CONCLUSION, WE HAVE A
MEDICAID AND ACO SAMPLE, WE DID
SEE AN ASSOCIATION WITH THE CTC
IN REDUCED RISK FOR MENTAL
HEALTH CARE UTILIZATION.
WE FOUND DIFFERENT FINDINGS FOR
MALE AND FEMALE AND WE'RE STILL
EXPLORING AND HAVE BEEN
DEMONSTRATED IN OTHER LITERATURE
THAT HAD EXAMINED THE AFFECT OF
THE CANADIAN CHILD BENEFIT BUT
WE HAVE PLANS IN OUR STUDY TO
ALSO EXPAND THIS BEYOND OHIO
USING THE DATA TO LOOK AT
DIFFERENT STATES AND ALSO TO
LOOK AT OTHER OUTCOMES SUCH AS
CONTINUATION OF MENTAL HEALTH
CARE AND THE ROLE CTC MAY HAVE
PLAYED AND ADOLESCENTS WHO HAVE
MENTAL HEALTH NEEDS TO CONTINUE
TO RECEIVE PHARMACO THERAPY
AROUND PATIENT VISITS.
>> THANKS SO MUCH, DR. CHAVEZ.
NOW WE'LL MOVE TO OUR Q&A
SESSION.
WE'RE ANSWER AS MANY QUESTIONS
AS POSSIBLE AND MAY COMBINE
SIMILAR QUESTIONS TO GET THROUGH
THEM.
I'LL START US OFF.
THE FIRST QUESTION WE HAVE IS --
DO YOU HAVE A CAPACITY
ASSESSMENT OR TOOL AVAILABLE TO
ASSESS ORGANIZATIONAL TO ENGAGE
IN RESEARCH IN A MEANINGFUL WAY
AND IDENTIFY STEPS THAT CAN BE
TAKEN COLLABORATIVELY BETWEEN
RESEARCHERS AND THE ORGANIZATION
TO ENHANCE CAPACITY AND INTEREST
IN ENGAGING IN RESEARCH.
>> THAT'S A HEFTY QUESTION BUT
THOUGH WE DON'T CALL IT
ASSESSMENT BUT I LIKE THE
TERMINOLOGY IT'S MORE
COMPLICATED THAN A CAPACITY
INVESTMENT.
WHILE WE DON'T CALL IT AN
INVESTMENT PER SE THE TOOL KIT
COVERS VARIOUS TOPICS THAT WOULD
BUILD TO A FULLER CAPACITY
ASSESSMENT.
SO WE HAVE -- WE START WITH
CHAPTERS ON DECIDING OVERARCHING
GOALS AND OBJECTIVES OF WHY
YOU'D WANT TO PARTNER AND TO
CENTER YOURSELF ON WHY YOU'D
WANT TO PARTNER AND WHAT THAT
MIGHT LOOK LIKE.
WE COVERED THE SPECTRUM OF
COMMUNITY ENGAGEMENT SO YOU CAN
DETERMINE WHERE IT'S FEASIBLE
FOUR AND THEN YOU SORT OF HOLD
YOURSELF TRUE AND PRESENT THAT
LEVEL OF ENGAGEMENT TO THE
COMMUNITY PARTNERS SO THERE'S
CLEAR EXPECTATIONS WHERE YOU'RE
AT ON THE SPECTRUM AND IN EACH
LEVEL OF THAT SPECTRUM HAS
DIFFERENT CONSIDERATIONS AND WE
ALSO INCLUDE A SECTIONAL
TRAINING WAS MENTIONED SO
TRAINING FOR YOUR RESEARCH TEAM
MEMBERS THAT YOU MIGHT CONSIDER
AND DO SPEND A FAIR AMOUNT OF
TIME WALKING THROUGH THE ROLE OF
THE EXPECTATIONS AND
INVESTIGATOR FOR THE RESEARCH
STAFF SO YOU THINK THROUGH THAT.
THERE ARE ALSO NUMEROUS
ADMINISTRATIVE CONSIDERATIONS WE
HAVE ENCOUNTERED.
AND SO THOSE REALLY NEED TO BE
THOUGHT THREE -- THROUGH AND
ADDRESSED SO WE HAVE A CHAPTER
ON THAT.
THE QUESTION MENTIONED THE
PRIVACY.
WE HAVE AN ENTIRE CHAPTER ON
ENSURING PRIVACY AND
CONFIDENTIALITY IT WAS BASED ON
PEOPLE WITH LIVED EXPERIENCE OF
SUBSTANCE USE AND HAS DIFFERENT
RAMIFICATIONS FOR DIFFERENT
POPULATIONS.
WE TRIED TO CAPTURE ALL WE
LEARNED THE PARTNERS WE WORK
WITH AND THERE WAS ENGAGEMENT AS
WELL.
WE HAVE SOME OF THAT INITIAL
ENGAGEMENT BUT THERE'S A FEW
CHAPTERS COMING IN JUNE.
WE HAVE A CHAPTER OF SUSTAINING
ENGAGEMENT COMING IN JUNE.
AND THEN TRAINING.
WE COVER ON BOARDING AND
TRAINING FOR THE COMMUNITY BOARD
MEMBERS FOCUSSED ON DIGESTING
RESEARCH AND A LOT OF THAT WE
PULLED TOGETHER OTHER PEOPLE'S
TOOLS.
SO THAT'S ANOTHER THING WE TRIED
TO DO WAS TO PULL TOGETHER TOOLS
THAT WE DID TO TRY TO BE HELPFUL
FROM FOLKS AND NOT RECREATE THE
WHEEL.
SOME OF THE FINAL CHAPTERS ARE
COMING OUT SO IT'S NOT QUITE
READY BUT CHECK BACK.
>> GREAT.
THANK YOU.
THE NEXT QUESTION IS FOR
DR. CHAVEZ.
LAURA, CAN YOU PLEASE DESCRIBE A
LITTLE BIT MORE ABOUT THE
QUALITY OF DATA YOU HAD
COLLECTED AND HOW IT HELPED WITH
YOUR INTERPRETATION OF THE
RESULTS.
>> THANKS FOR THAT QUESTION.
THE QUALITATIVE DATA WARE STILL
DOING THE CODING FOR SO THAT'S
MORE LABOR INTENSIVE TO HAVE
RESULTS READY FOR PRESENTATION
BUT WE INTERVIEWED WITHIN THE
MEDICAID ACL PARENTS OF
ADOLESCENTS WHO HAD A BEHAVIORAL
HEALTH NEED.
INTERVIEWED THEM ABOUT THE
EXPERIENCE RECEIVING THE CHILD
TAX CREDIT AS WELL AS THE OLDER
ADOLESCENT TAX CREDIT IMPACTED
FAMILY DYNAMICS.
WE HAD INTERESTING PRELIMINARY
FINDING LIKE I SAID WE'RE STILL
WORKING THROUGH THE CODING.
THAT'S THE KEY IN TRYING TO
UNDERSTAND THE COMPLICATED
POLICIES.
TO HEAR THE VOICES FROM
CAREGIVERS TO UNDERSTAND WHAT
THE EXPERIENCE WAS LIKE AND
UNDERSTAND FINDINGS AS WELL.
>> NEXT QUESTION I HAVE ISES
WHAT INNOVATIVE METHODS CAN BE
EMPLOYED TO INTEGRATE PARTNER
FEEDBACK INTO RESEARCH.
KIMBERLY MIGHT INVITE TO YOU
ANSWER FIRST.
>> MIXED METHODS IS RELATIVELY
STANDARD BUT THE WAYS YOU CAN
IMPLEMENT CAN DIFFER.
IN OUR CURRENT STUDY WE HAVE
ACCIDENTALLY FALLEN INTO THE
QUANTITATIVE AND QUALITATIVE AT
THE SAME TIME DUE TO LOGISTICAL
CONSTRAINTS BASICALLY.
ONE THING THAT'S BEEN USEFUL FOR
US IS LISTENING AND READING
PARTICIPANT INTERVIEWS TO FIGURE
OUT WHETHER THEY'RE SAYING
THINGS THAT WE COULD LOOK AT IN
QUANTITATIVE DATA THAT WE MIGHT
NOT HAVE THOUGHT OF OTHERWISE.
THESE MIGHT NOT BE THINGS THAT
RISE TO THE LEVEL OF A FULL
THEME IN QUALITATIVE ANALYSIS
BUT IF A PARENT IS MENTIONING I
NEED TO GO PART-TIME TO ATTEND
THE APPOINTMENTS WE MAY BE ABLE
TO SURVEY DATA IF WE SEE
DIFFERENCES IN PARENT EMPLOYMENT
OR ANYTHING LIKE THAT.
I THINK THIS CAN REALLY MOVE THE
RESEARCH FORWARD IS FIGURING OUT
WHAT CAN WE DO IN THIS STUDY AND
WHAT CAN WE DO IN FUTURE STUDIES
TO UNDERSTAND WHAT PARENTS ARE
REPORTING AS IMPORTANT AND
UNDERSTAND THAT IN THE
QUANTITATIVE DATA.
>> THANK YOU SO MUCH.
MAYBE ANOTHER QUESTION FOR THE
PANEL.
I KNOW SOME OF YOU ALREADY SPOKE
TO THIS BUT OTHER INNOVATIVE
METHODS TO BE EMPLOYED TO
INCORPORATE PARTNER FEEDBACK.
ANY SUGGESTIONS?
>> I'LL JUMP IN.
I'LL ADD THE PLUG AGAIN FOR
MAKING YOUR RESEARCH TEAM A
PLACE PREPARED FOR AND WELCOMING
FOR PEOPLE WITH LIVED EXPERIENCE
TO WORK ON YOUR RESEARCH TEAM AS
RESEARCHERS ON YOUR RESEARCH
TEAM.
SOMETIMES I'VE BEEN FORTUNATE
BECAUSE OF THE JEAP NIRNT --
INITIATIVE HAVING SUPPORTS BUILT
OUT AND LEARN PROCESSES FOR
IMPROVING THE ABILITY TO DO
THAT.
ASIDE FROM WORKING DIRECTLY ON
THE RESEARCH, WE'VE DONE A TON
OF WORK ON COMMUNITY BOARDS ALSO
KNOWN AS COMMUNITY ADVISORY
BOARDS OR CABS, I PREFER TO MAKE
IT A PARTNERSHIP THAN AN
ADVISORISHIP.
WE FOCUS ON COMMUNITY BOARDS,
OUR PANELS.
WE ALSO PARTNER WITHIN THAT WORK
WE PARTNER WITH THEM IDENTIFYING
DIFFERENT PROJECTS AND
IDENTIFYING WHAT SHOULD BE
RESEARCHED IN THE FIRST PLACE.
CONCEPTUALIZING PROJECTS AND
PROCEDU
PROCED
PROCEDURES PROBLEM SOLVING AND
INTERPRETING THE FINDINGS AND IN
PARTICULAR MAKING SURE THAT OUR
INTERPRETATION AND THE WAY WE'RE
GOING TO DISSEMINATE THINGS
ISN'T GOING TO CAUSE HARM TO
THEIR COMMUNITY.
ALSO DISSEMINATION PLANS.
HOW TO GET THE WORK OUT THERE.
AND WHAT ARE THE NEXT STEPS.
WE'VE DONE THE RESEARCH AND
CONCLUDED WHAT ARE THE NEXT
STEPS.
WE'VE ALSO DONE LIKE PUBLIC
FORUMS WHERE IT'S REALLY
INTENDED TO BE A DISCUSSION
BETWEEN RESEARCHERS AND PEOPLE
WITH LIVED EXPERIENCE.
WE DO LISTENING SESSIONS SORT OF
ONE TIME KIND OF THINGS AND THEN
OF COURSE THE QUALITATIVE
RESEARCH AND MIXED METHODS
KIMBERLY WAS TALKING ABOUT.
AGAIN THOUGH WITH ANY OF THOSE
IT'S CRITICAL TO PAUSE AND MAKE
SURE THAT YOU HAVE PREPARED
YOURSELF AND YOUR TEAM REALLY
WELL SO YOU DON'T PERPETUATE
MORE HARM TO COMMUNITIES THAT
MAY HAVE BEEN HARMED BY
RESEARCHERS.
>> I WAS WONDERING IF OTHER
PANELISTS ALSO HAD COMMENTS ON
THAT.
SORRY, KELLY.
IF NOT MAYBE ANOTHER QUESTION,
KELLY, YOU WANTED TO RAISE?
>> YEAH.
OUR NEXT QUESTION IS HOW CAN
ENGAGING MENTAL HEALTH AND
SUBSTANCE USE D
SUBSTANCE USE DISORDER
STAKEHOLDERS CHANGE THE APPROACH
OR METHOD?
IF YOU HAVE ANY ADDITIONAL
EXAMPLES IT WOULD BE REALLY
HELPFUL.
>> READ THAT ONE MORE TIME.
>> HOW CAN ENGAGING MENTAL
HEALTH AND SUBSTANCE USE
DISORDER STAKEHOLDERS IN
RESEARCH CHANGE THE RESEARCH
APPROACH QUESTIONS OR METHODS
AND I THINK IF THERE'S EXAMPLES
YOU ALL HAVEN'T DISCUSSED OR
PART OF YOUR PREPARATION IT
WOULD BE HELPFUL.
>> I DIDN'T GET TO MENTION WE
HAVE A COMMUNITY ADVISORY GROUP
FOR THE STUDY THAT HELPED US A
LOT IN DEVELOPING OUR INTERVIEW
GUIDES AND PILOT INTERVIEW
GUIDES.
THE VALUE OF THE QUALITATIVE
DATA IS CONTINGENT ON ASKING THE
RIGHT QUESTIONS AND YOU DON'T
KNOW UNLESS YOU DO THE WORK
AHEAD OF TIME AND STAKEHOLDERS
AND PARTNERS IN RESEARCH ARE
CRITICAL TO THAT.
>> I TOTALLY AGREE WITH THAT AND
ONE THING WE'RE THINKING ABOUT
IS SORT OF HOW TO ASK ADDITIONAL
QUESTIONS IN THE FUTURE THAT
HAVE COME UP.
WE'RE HEARING ABOUT THE USE OF
CRISIS SERVICES IN LIEU OF E.D.
SERVICES AND THINKING WHAT ARE
THE NEXT STEPS IN THAT AREA OF
RESEARCH FOR PEDIATRIC
POPULATIONS THAT HAVE BEEN LESS
STUDIED.
>> MY ANSWER COVERED IN THE LAST
ANSWER I GAVE ABOUT EVERYTHING
FROM OUR BOARDS HAS BEEN A PART
FROM CONCEPTUALIZING THE
RESEARCH QUESTIONS THEMSELVES TO
HELPING US DETERMINE HOW TO GO
AFTER AND EXAMINE THE RESEARCH
QUESTIONS, CHANGE SOME OF THE
WAY WE MEASURE THINGS SOME OF
THE PROCEDURES IN THE RESEARCH
STUDIES AND THE WAY WE DO
RECRUITMENT TO INTERPRETING AND
DISSEMINATION.
THE FULL RANGE THAT HAD IMPACT
IN DIFFERENT WAYS ALONG THE WAY.
>> GREAT, WELL THANK YOU, ALL,
LAU
LAURA, KIMBERLY AND THANK YOU.
>> WE HAVE A FINAL REFLECTIONS
AND NEW DIRECTIONS IN CLOSING
REMARKS FROM DR. SCHACKMAN AND
DR. CASTEDO DE MARTELL.
TAKE IT AWAY.
>> THANKS SO MUCH FOR THE
INTRODUCTION, JENNIFER.
I'M SIERRA NEW HERE AND HAD BEEN
OUT ON MATERNITY LEAVE.
I WANTED TO SAY IT WAS EXCITING
TO SEE SOME FAMILIAR FACES BUT
ALSO TO HAVE THE OPPORTUNITY TO
SEE A LOT OF NEW FACES OR NEW TO
ME, ANYWAY.
I'M LOOKING FORWARD TO
CONTINUING TO SUPPORT THOSE
DOING NIDA FUNDED HEALTH
ECONOMIC RESEARCHES WHEN I FULLY
RETURN FROM MATERNITY LEAVE IN A
COUPLE WEEKS AND DR. SCHACKMAN
AND I WILL WRAP THINGS OFF WITH
SOME CLOSING REMARKS AND WANTED
TO DOES A QUESTION TO
DRDR
DR. SCHACKMAN WHAT YOU SAW ABOUT
THE KEY TAKEAWAYS FROM TODAY'S
PRESENTATIONS?
>>
>> I'M BRUCE SCHACKMAN FROM
WEILL CORNELL MEDICAL COLLEGE
AND JUST AN ADD, DR. MURPHY
SPOKE EARLIER AS HEAD OF OUR
CONSULTATION SERVICE FOR
RESEARCHERS WHO WANT HELP
GETTING STARTED IN THIS AREA.
IT'S FREE ALSO.
SO ALSO, THANK YOU TO THE ALMOST
180 PEOPLE STILL STICKING WITH
US.
IT'S BEEN A VERY RICH BUT ALSO
EXHAUSTING SET OF PANELS.
I THINK THEME OVER ALL IS
EVERYONE IS FOCUSSED ON REAL
WORLD APPLICATIONS.
WE REALLY APPRECIATE AND
SPEAKING FOR SIERRA AND MYSELF,
HOW MANY OF THE PRESENTATIONS
FOCUSSED ON INTEGRATED
INTERVENTIONS.
INTEGRATING BETWEEN MENTAL
HEALTH AND BEHAVIORAL AND
PRIMARY CARE.
THOSE ARE THE CONTEXT, IF YOU
WILL.
WHAT I CAME AWAY FROM ONE OF THE
BIGGEST THEMES IS TOOLS, TOOLS,
TOOLS, TOOLS.
TOOLS ARE REALLY HELPFUL WE HOPE
FOR REAL WORLD APPLICATION.
THE IMPLEMENTATION COSTING TOOLS
LIKE COINS CAN HELP SUPPORT
DECISIONS WHETHER TO ENGAGE IN
IMPLEMENTATION OF PROCESS NORT
AND HAVE A REAL UNDERSTANDING
WHAT THAT INVOLVES.
AND THEY ALSO POOLS ALSO PROVIDE
OPPORTUNITIES FOR COMMON
MEASURES SUCH AS THOSE THAT
DR. MURPHY REFERRED TO IN THE
JCOIN PRESENTATION.
THE OTHER SIDE OF THE TOOLS THAT
WAS STIMULATING IS THINKING
ABOUT PAYMENT AND PAYMENT
DESIGN.
THAT REFLECT REFLECTS THE APPR
WE ALL GOT OF THE GREAT
COMPLEXITY OF HAVING MULTIPLE
PAIRS AND CONSTRAINTS AND
APPROACHES AND INCENTIVES AND
HOW TO BRING IT TOGETHER TO
PROVIDE THE SERVICE OR MAKE A
DECISION ABOUT HOW TO PROVIDE
THE SERVICE.
ANOTHER THING WE BOTH TOOK AWAY
WE TALKED ABOUT BEFORE IS
EFFECTIVE RESEARCH REQUIRES
MULTIPLE PERSPECTIVES AS IT WAS
TALKED ABOUT IN THE LAST PANEL.
IN PARTICULAR I LIKE THE
OBSERVATION THAT NO ONE HAS THE
FULL PICTURE.
EVERYONE HAS AN ANGLE ON THE
PICTURE AND WE NEED DIFFERENT
PIECES OF THE PUZZLE.
PEOPLE WITH LIVED AND LIVING
EXPERIENCE AND FAMILY MEMBERS
PARTICULARLY WHAT VALUES THEY
VALUE AND SEE AS IMPORTANT TO
STUDY AND THE IMPLEMENTERS IN
THE WORK FLOWS AND PAYERS TO
UNDERSTAND HOW THEY BALANCE
BEHAVIORAL AND NON-BEHAVIORAL
COSTS AND THOSE ARE SOME
EXAMPLES.
THERE'S MANY PIECES OF THE
PUZZLE AND NEED INPUT FROM MANY
STAKEHOLDERS AND NEEDS DIVERSE
TEAMS TO DO ECONOMIC RESEARCH.
FINALLY, I WOULD SAY THE POLICY
IMPACT.
VERY CHALLENGING TO IDENTIFY
IMPACTS OF POLICYIES IT'S ALSO
COMPLEX WHEN THERE'S MULTIPLE
POLICIES GOING ON AT THE SAME
TIME OR MAY INTERACT WITH ONE
ANOTHER AND TO THINK ABOUT
IMPACTS ON BOTH DEMAND AND
SUPPLY.
A LARGER DISCUSSION ABOUT THE
SUPPLY OF PROVIDERS AND HOW THAT
MAY BE TOUGH TO APPROACH WITH
POLICIES.
ONE POSITIVE THING AND
INTERESTING THING I TOOK AWAY IS
THERE ARE POLICIES NOT FOCUSSED
ON BEHAVIORAL HEALTH THAT HAVE
SOME POTENTIALLY PROMISING
IMPACT.
THINGS LIKE SICK LEAVE OR THE
CHILD TAX CREDIT.
THOSE HAVE THINGS NOT DESIGN FOR
BEHAVIORAL HEALTH IMPACT BUT
SEEM TO HAVE A POTENTIAL FOR
IMPACT IN CERTAIN COMMUNITIES.
I THINK DOING MORE RESEARCH IN
THAT AREA WOULD BE GREAT.
THAT'S ALL I WANT TO SAY RIGHT
NOW, SIERRA.
I WANT TO TURN IT BACK TO YOU
AND ASK YOU WHAT YOU TAKEAWAY IN
TERMS OF FUTURE DIRECTIONS FOR
THE FIELD.
>> YEAH, THANKS SO MUCH FOR
THOSE THOUGHTS.
I WANTED TO START BY POINTING TO
A COUPLE YEARS AGO A COMMENTARY
THAT EXPANDED UPON THE
CONSOLIDATED HEALTH ECONOMIC
REPORTING STANDARD FOR THOSE WHO
AREN'T FAMILIAR WITH THOSE.
AND THAT COMMENTARY CALLED FOR
GREATER INVOLVEMENT OF THE
PUBLIC AND PATIENT POPULATIONS
IN ECONOMIC EVALUATION RESEARCH.
BECAUSE THEY'LL BE BEARING A LOT
OF THE IMPACT OF DECISIONS MADE
BASED ON THE ECONOMIC
EVALUATIONS.
AND SO AS IT WAS POINTED OUT,
THAT'S A COST CUTTING THEME.
SINCE IT'S PART OF THE EMERGING
GUIDELINES ACROSS ECONOMIC
EVALUATION WRIT LARGE, WE
DEFINITELY SEE THAT AS A
POTENTIAL FUTURE DIRECTION AND
SOMETHING THAT COULD CONTINUE TO
GROW AND CONTINUE TO DEVELOP.
SIMILARLY, AS WE'RE INVOLVING
THOSE PERSPECTIVES, THERE'S A
REAL OPPORTUNITY FOR CONDUCTING
DISSEMINATION SCIENCE RESEARCH
TO DEVELOP AND TEST THOSE TOOLS
FOR THOSE DIFFERENT AUDIENCES
DR. SCHACKMAN ALLUDED THIS WHEN
HE REFERRED TO TOOLS, TOOLS,
TOOLS.
THEY WORK, WE THINK.
WE WANT TO SEE IF THEY'RE HAVING
THE KINDS OF IMPACTS WE WANT TO
SEE AND MAYBE IF WE HAVE MORE
INFORMATION, DOES IT LEAD TO
BETTER DECISIONS?
WE HAVE THE WORLD OF INFORMATION
AT OUR FINGER TIPS WITH THINGS
LIKE THE INTERNET BUT HAVEN'T
SOLVED THE WORLD'S PROBLEMS JUST
YET SO IT'S IMPORTANT TO SEE IF
THEY HAVE THE KIND OF IMPACT WE
HOPE.
I KNOW WE HAVE A FEW WRAP UP
STATEMENTS FROM SOME OF OUR
ORGANIZERS.
I WANT TO GO AHEAD AND TURN IT
BACK TO THEM WITH ONE MORE THANK
YOU TO ALL OUR EXCELLENT
SPEAKERS AND ORGANIZATION TEAM
AND HAND IT BACK TO DR. HUMENSKY
TO CLOSE US OUT.
>> THANK YOU TO BRUCE AND SIERRA
FOR TAKING THE TIME TO SUMMARIZE
THE MEETING AND PULLED TOGETHER
THE THEMES THAT IS HELPFUL TO 43
WITH THE BREADTH OF DISCUSSIONS
WE HAD TODAY.
I APPRECIATE YOU TAKING THE TIME
TO TIE IT ALL TOGETHER.
WE WANTED TO JUST TAKE THE
OPPORTUNITY TO THANK A FEW
PEOPLE WITHOUT WHOM TODAY'S
MEETING COULDN'T HAVE HAPPENED.
FIRST, THANK YOU TO ALL OF
TODAY'S SPEAKERS AND THEIR
RESEARCH TEAMS FOR DOING THIS
IMPORTANT WORK.
WE'RE LEARNING MORE ABOUT HOW
OUR MARKETS FUNCTION AND HEALTH
CARE SYSTEMS FUNCTION AND HOW WE
CAN BEST SERVE PATIENTS AND
FAMILIES.
WE'LL ALSO THANK THE
FACILITATORS WHO PROVIDE THEIR
PERSPECTIVES ON THESE ISSUES AND
WE APPRECIATE YOU TAKING THE
TIME TO DO SO.
WE WANT TO THANK THE FOLKS
LISTED AND COULDN'T HAVE DONE IT
WITHOUT YOU AND THE NIH
VIDEOCAST TEAM AND BOB HAMNER
AND KEVIN AND FOLKS AT THE
MEETING AND TWO RETIRED SARAH
DUFFY AND TAMARA WHO WERE
INSTRUMENTAL IN DEVELOPING THIS
MEETING PRIOR TO THEIR
RETIREMENTS AND THANK THEM FOR
THEIR SUPPORT AND CONTRIBUTIONS.
WE THANK LINDSEY MARTIN FOR
PICKING UP THE TORCH AFTER THE
RETIREME
RETIREMENTS AND SUPPORTIVE
OPENING REMARKS EARLIER TODAY.
I WANT TO THANK THE NIMHD FOLKS
WHO SUPPORTED THE MEETING.
A RECORDING OF THE MEETING WILL
BE AVAILABLE AT NIH VIDEOCAST
AND VIEWED AT YOUR CONVENIENCE
AND ENJOY THE REST OF YOUR DAY.