My Background. Agenda 7/21/14 HEALTHCARE TRANSFORMATION IN MULTNOMAH COUNTY

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Alexandra Stevenson
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1 HEALTHCARE TRANSFORMATION IN MULTNOMAH COUNTY What s changing and why Devarshi Bajpai Addiction Services Manager Multnomah Mental Health and Addictions My Background Addictions treatment provider DePaul, Hooper, ASAP, CCC Oregon Addictions/MH Methadone, Methamphetamines, Older Adult policy Oregon Criminal Justice Commission Drug Courts, Prisoner Reentry, Law Enforcement Multnomah 2012-now Agenda What it was like Public system funding in Multnomah System strengths Fragmentation, Weaknesses What happened Affordable Care Act, Block Grant What it s like now Future addiction treatment system 1

Public Funding of Addiction Mission - The Multnomah Board of Commissioners plans for the needs of a dynamic community, provides leadership to ensure quality services, prioritizes the needs of our

2 Public Funding of Addiction Mission - The Multnomah Board of Commissioners plans for the needs of a dynamic community, provides leadership to ensure quality services, prioritizes the needs of our most vulnerable and promotes a healthy, safe and prosperous community for all. Addiction Public Funding Reducing demand for drugs Recovery Preventing chronic and infectious disease Preventing homelessness Reducing criminal activity Reducing child abuse and neglect 5 Does it reduce criminal recidivism? 2

3 2013 Oregon HB 3194 Saves $300 million over 10 years Creates $15 million Justice Reinvestment Grants Increases Community Corrections funding by $17 million 3

Commission Budget $70,000,000 $60,000,000 $50,000,000 $40,000,000 $30,000,000

4 Oregon Criminal Justice Commission Budget Budget increased from $2.5 million in 2005 to $25 million in 2013 Devarshi starts Oregon Criminal Justice Commission Budget $70,000,000 $60,000,000 $50,000,000 $40,000,000 $30,000,000 $20,000,000 $10,000,000 Devarshi leaves $ Does it reduce medical costs? 4

Medicaid Savings In comparison of medical expenses for welfare clients in Washington State it was determined that substance abuse treatment was associated with a reduction in expenses of $2,500 per

5 Medicaid Savings In comparison of medical expenses for welfare clients in Washington State it was determined that substance abuse treatment was associated with a reduction in expenses of $2,500 per year. In reviewing selected beneficiaries in Oregon s Medicaid program, researchers concluded that eliminating the substance abuse benefit led to increased medical expenditures. A review of over 1,000 patients in a Sacramento chemical dependency program noted a substantial decline in hospital (35%), emergency room (39%), and total medical costs (26%) when compared to a control group. Source: SAMHSA Multnomah funding Public Funding Federal Government State Medicaid State AMH Health Plans Providers 5

6 Federal Government $600,000 State Medicaid State AMH $4,722,084 $10,262,401 Health Plans Providers Current Multnomah System Detox Residen1al Outpa1ent Recovery Support OHP Physical Health Plan Physical Health Plan??? Uninsured System problems A good system that can be better 6

7 Hooper Detox Admissions October-December individual admissions 701 Homeless Appx 60% heroin, 40% alcohol 578 repeat admissions 62 Transitioned to CCC Housing Residential Approximately 600 admissions/year 4-6 week waitlist $ per day- set in 1999 No resources for high utilizers 8 of 5,000 Healthshare high utilizers accessed residential 7

Rough estimates for Oregon s Medicaid population 2% 18% Don't need Need don't get Need and get 80% Primary

don t know how to refer to treatment There is no capacity in treatment My patients don t follow through

Addictions (State of Oregon DMAP Data) CareOregon Tri Claims Data: 21% Adults have 1+ chronic condi1on PLUS

8 Rough estimates for Oregon s Medicaid population 2% 18% Don't need Need don't get Need and get 80% Primary Care/Addiction System Screening, Brief Intervention, and Referral to (SBIRT) an incentive measure for CCO Doctors I don t know how to refer to treatment There is no capacity in treatment My patients don t follow through Legacy/DePaul Doctors referred the most obvious cases for screening Very High Prevalence of Mental Health and Addictions (State of Oregon DMAP Data) CareOregon Tri Claims Data: 21% Adults have 1+ chronic condi1on PLUS substance abuse or schizophrenia + bipolar disorder; 3%, both. Based on HSO 160,000 members (40% Adult). 21% Adults = 13,440; 3% Adults = 1920 (no FFS) 8

Clarifying Mul1morbidity PaTerns to Improve Targe1ng and Delivery of Clinical Services for Medicaid Popula1ons Cynthia

Carlos Weiss, Jennifer Wolff, Allison Hamblin, and Lorie Mar1n CHCS DECEMBER 2010 Where is the $$$ going?

Hospitalizations and ER admits amount to 43% of Billed Charges * Outpa1ent Behavioral includes mental health services and

9 Clarifying Mul1morbidity PaTerns to Improve Targe1ng and Delivery of Clinical Services for Medicaid Popula1ons Cynthia Boyd, Bruce Leff, Carlos Weiss, Jennifer Wolff, Allison Hamblin, and Lorie Mar1n CHCS DECEMBER 2010 Clarifying Mul1morbidity PaTerns to Improve Targe1ng and Delivery of Clinical Services for Medicaid Popula1ons Cynthia Boyd, Bruce Leff, Carlos Weiss, Jennifer Wolff, Allison Hamblin, and Lorie Mar1n CHCS DECEMBER 2010 Where is the $$$ going? % of Total Billed Charges by Service (State of Oregon Medicaid Data) 2009 Total Billed Charges = $1,630,851,673 Hospitalizations and ER admits amount to 43% of Billed Charges * Outpa1ent Behavioral includes mental health services and ER and non- ER chemical dependency services 9

10 Ultimate Cost What s Changing? Addictions System // What is Changing The Affordable Care Act: Medicaid expansion means more of our clients will have insurance coverage Mental Health and Addictions treatment included in the 10 essential health benefits Medicaid mandates that there not be waitlists for covered services for many criminal risk factors will not be covered 10

11 Coordinated Care Organizations Combine physical, mental, and dental health budgets into a single global budget Statewide $4 billion budget Performance metric incentive funding Pressure from federal government to flatten the cost curve $1.9 billion at stake Coordinated Care Organizations Medicaid members assigned to one of two CCO s in tri-county (Multnomah, Clackamas, Washington) region- FamilyCare Healthshare n 7 Risk Accepting Entities (RAE s) n Physical Health (CareOregon, Providence, Kaiser, Tuality) n Detox and Outpatient n Mental Health/ n Residential Current Multnomah System Detox Residen1al Outpa1ent Recovery Support OHP Physical Health Plan Physical Health Plan??? Uninsured 11

Oregon Uninsured Uninsured rate dropped from 17% to 6% Second largest drop in nation Places us 5 th lowest

12 Changing Addictions System // What is Changing Many supports that our clients need to be successful won t be paid for by Medicaid: Supported Housing Child Care Peer Support CCO Medicaid Dollars Employment Support 34 Oregon Uninsured Uninsured rate dropped from 17% to 6% Second largest drop in nation Places us 5 th lowest uninsured rate Uninsured Outpatient Adult Utilization 140% 120% 100% 80% 60% 40% 20% 0% Oct Nov Dec Jan Feb 12

13 Opportunity Medicaid expansion Stable funding Federal Block Grant State General Fund General Fund $4,722,084 $600,000 $10,262,401 Problems No connection between levels of care Weak connection between primary care and addiction treatment Residential waitlists Lack of continuum of care Lack of housing and supports Current Multnomah System Detox Residen1al Outpa1ent Recovery Support OHP Physical Health Plan Physical Health Plan??? Uninsured 13

Acute vs Chronic Addiction a chronic condition often requiring lifelong management

30-50% Hypertension = 50-60% Asthma = 60-80% Addiction = 30-50% Addiction = 40-70% 40

Health Plan DCJ/DCHS Day Physical Health Plan DCJ/DCHS Uninsured DCJ/DCHS Housing DCJ/DCHS

14 Acute vs Chronic Addiction a chronic condition often requiring lifelong management Compliance Rates Relapse Rates Diabetes = <50% Hypertension = <30% Asthma = <30% Diabetes = 30-50% Hypertension = 50-60% Asthma = 60-80% Addiction = 30-50% Addiction = 40-70% 40 Desired System Detox Residen1al Day + Housing Outpa1ent Recovery Support OHP Physical Health Plan DCJ/DCHS Day Physical Health Plan DCJ/DCHS Uninsured DCJ/DCHS Housing DCJ/DCHS Reinvestments Uninsured Clients Assessment Individual Counseling Group Counseling Urinalysis Case Management 14

15 Not covered by insurance Peer mentors Skills training Childcare Housing Criminality Promising Projects Primary Care Consultation/Referral Safety Holds and Emergency Room Hand-off Housing with Intensive Outpatient Partial Hospitalization Future of Addictions System Comprehensive continuum of care with shorter residential stays Short residential waitlists Clean and sober housing capacity Recovery supports such as child care, job assistance, transportation, peer mentoring for criminality integrated with addictions treatment 15

Sustaining vs Disruptive Innovation A sustaining innovation makes us better at doing what we do. A disruptive innovation changes what it is we do.

16 Sustaining vs Disruptive Innovation A sustaining innovation makes us better at doing what we do. A disruptive innovation changes what it is we do. Sustaining vs Disruptive Innovation Sustaining innovation Assembly Line Lean, Six Sigma, Reengineering, etc Disruptive innovation Automobile (horse drawn carriage) Mp3 players(physical media- cassette, CD) Smartphone (gps devices, mp3 players, handheld gaming) Alcoholics Anonymous (Jails, Hospitals, Death) Disruptive Innovation What s our next disruptive innovation? Addiction Comprehensive Health Enhancement Support System (ACHESS) Medication Online counseling Something else? 16

17 Thanks! Devarshi Bajpai 17

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