Medicaid Beneficiaries and Serious Mental Illness

Arlington, Virginia—Medicaid patients with serious mental illness are less inclined to adhere to their medications, visit providers, and undergo preventive services. Many also have chronic conditions and risk factors such as smoking, poor diet, and minimal exercise. Those problems prompted UPMC Health Plan Inc, a subsidiary of the University of Pittsburgh Medical Center, to develop a partnership among health plans, primary care physicians, and behavioral health (BH) providers to help coordinate care for patients with serious mental illness. John G. Lovelace, vice president at UPMC, spoke about the company’s Connected Care program at the Medicaid Managed Care Summit during a presentation titled Improving Health Outcomes for Medicaid Beneficiaries with Serious Mental Illness—A Multi-Stakeholder Approach. He said the program is focused on the patient-centered medical home model that includes an integrated team and care plan and addresses medical, behavioral, and social needs. As part of the program, UPMC partnered with the Center for Health Care Strategies, the Department of Public Works, the Community Care behavioral health organization, and the Allegheny County (Pennsylvania) Department of Human Services. According to Mr. Lovelace, patients with serious mental illness die at an average age of 51 years compared with an average of 76 years for the general US population. They are also 3.4 times more likely to die from heart disease, 3.4 times more likely to die from diabetes, 3.8 times more likely to die from accidents, 5.0 times more likely to die from respiratory ailments, and 6.6 times more likely to die from pneumonia or influenza. Patients with serious mental illness have high rates of diabetes, hypertension, obesity, and hyperlipidemia, and 22% to 60% have metabolic syndrome as a result of antipsychotic medications. Patients were included in the Connected Care program if they were a member of the UPMC for You or UPMC for Life specialty plan and Community Care, were ≥18 years of age, lived in Allegheny County, and had a serious mental illness, which was defined as a diagnosis of a schizophrenic disorder, episodic mood disorder, or borderline personality disorder. Members were identified as having high physical health (PH) needs or high BH needs. The high PH group was defined as ≥3 visits to the emergency department in the past 3 months or ≥3 inpatient admissions in the past 6 months. The high BH group was defined as patients who had been discharged from, served at, or diverted from a state mental hospital; had ≥5 admissions to the most restrictive level of care or had been readmitted within 30 days; had ≥4 admissions to the most restrictive level of care or had been an inpatient or been admitted to a residential treatment or commercial treatment facility; had ≥3 admissions to the most restrictive level of care and had been an inpatient; or had ≥2 admissions to the most restrictive level of care and had been an inpatient and had received open authorization for certain services. From July 2009 through December 2010, the program had 6318 members who were identified from claims data and categorized in 3 groups: 424 were in the high BH/PH and high PH/low BH group; 1703 were in the high BH/low PH group; and 4191 were in the low BH/low PH group. According to Mr. Lovelace, the Connected Care program focuses on integrating care and improving discharge planning, optimizing outcomes, and reducing voidable readmissions. PH and BH care managers received training on the program’s design and workflows. Mr. Lovelace shared some the preliminary outcomes in the Medicaid population for members identified from July 2009 through December 2009, with claims paid between July 1, 2009, and June 30, 2010. The baseline group included the 4953 members who were identified with serious mental illness from July 1, 2008, to June 30, 2009. The 6-month group included the 5463 members who were identified with serious mental illness from July 1, 2009, to December 31, 2009. There were 685 members with PH admission (273.56 members per 1000) at baseline compared with 838 members with PH admission (294.07 members per 1000) after 6 months. There were 950 members with BH admission (361.6 members per 1000) at baseline compared with 674 members with BH admission (240.4 members per 1000) after 6 months, which was a statistically significant difference. The program defined readmissions as people who were readmitted within 30 days for any diagnosis. There were 146 members with PH readmission (62.06 members per 1000) at baseline compared with 88 members with PH readmission (30.06 members per 1000) after 6 months, which was a statistically significant difference. There were 177 members with BH readmission (64.08 members per 1000) at baseline compared with 133 members with BH readmission (46.45 members per 1000) after 6 months, which was a statistically significant difference. In addition, there were 208 members with PH and BH admission (4.2% of unique members per 1000) at baseline compared with 158 members with PH and BH admission (2.9% of unique members per 1000) after 6 months, which was a statistically significant difference. There were 1963.1 emergency department visits per 1000 (54.6% of unique members who visited the emergency department) at baseline, compared with 1875.1 emergency department visits per 1000 (52.2% of unique members who visited the emergency department) after 6 months, which was a statistically significant difference. Mr. Lovelace also discussed BH and PH savings. Approximately 5500 members were in the Connected Care program, accounting for 59,414 member months. During fiscal year 2010, the number of people readmitted for BH declined 17.63 per 1000 members, whereas the number of people readmitted for PH declined 32.06 per 1000 members. The program’s leaders calculated that the program realized $609,000 in BH savings and $1,303,500 in PH savings in 2010. Mr. Lovelace said it would be reasonable to assume that they could realize between $500,000 and $600,000 in annual BH savings and between $1 million and $1.3 million in annual PH savings. Mr. Lovelace said program leaders will continue to measure the program’s effectiveness using several metrics calculated on an annual basis. These include the inpatient admissions per 1000, emergency department visits per 1000, the percentage of members with ≥1 primary care physician wellness visit, the percentage of members with ≥1 preventive dental examination, the percentage of diabetic members who have examinations and screening tests, and lifestyle risk factors such as the percentage of members enrolling in a health plan smoking cessation program and the percentage of members with a body mass index >30.