James Schuster, MD, MBA
I begin by first providing some background information as to the context from which I approach the very important topic of adequate and timely access to behavioral health services here today. I am the Chief Medical Offer for Community Care Behavioral Health Organization of UPMC.
Community Care Behavioral Health Organization is a 501(c)(3) tax exempt, nonprofit Pennsylvania-based behavioral health managed care organization. Community Care was created primarily to respond to the behavioral health needs of members of HealthChoices, Pennsylvania’s mandatory behavioral health managed care program for Medicaid recipients. Community Care also serves UPMC Health Plan’s commercial and Medicare members, via service cooperation agreements. Community Care currently employs more than 500 people to serve individuals in 36 counties in Pennsylvania and 16 counties in New York. We manage the behavioral health services for over 650,000 Medicaid eligible persons, approximately 23% of whom are active consumers of care.
Community Care’s approach to behavioral health managed care is grounded in public sector commitment, expert clinical competencies, and both program and fiscal accountability. It is and has long been Community Care’s philosophy that, in the end, quality is best measured by the improved health and well-being of the communities that we serve. Community Care is committed to continuous and systematic quality improvement across all domains.
UPMC is an integrated payer-provider headquartered in Pittsburgh, Pennsylvania, which includes a comprehensive provider-based clinical delivery system, a suite of health insurance and health management companies, and a longstanding collaboration with the University of Pittsburgh, a premier academic institution. With 20 hospitals, more than 55,000 employees, 2,700 employed physicians, 2,500 independent but affiliated physicians, thousands of mid-level providers, 400 clinical locations, and insurance companies offering commercial, Medicare and Medicaid products, all of which have large contracted networks, UPMC operates amongst the largest integrated delivery and financing systems in the nation.
UPMC is organized into four major operating units: Physician Services, Hospital Operations, Insurance Services, and International and Commercial Services. Community Care is in the UPMC Insurance Services Division which also includes physical health plans that operate in the Commercial, Medicare and Medicaid markets. Collectively, Community Care and the associated companies of the UPMC Health Plan offer health coverage products and services to nearly 1.8 million members.
UPMC Health Plan, the second-largest health insurer in western Pennsylvania, offers a full range of commercial and government products and services, including commercial group health insurance, Medicare, Medical Assistance, Special Needs (SNP), and Children’s Health Insurance (CHIP), as well as disease management and behavioral health programs. The UPMC Health Plan’s provider network includes more than 90 hospitals (including academic, advanced care, and specialty hospitals), cancer centers, physician practices (including more than 9,800 physicians), and long-term care facilities. Collectively, the network represents one of the largest and most diverse teams of health care professionals in Pennsylvania.
ACCESS AND BEHAVIORAL HEALTH SERVICE DELIVERY AND PAYMENT
Achieving and maintaining only the highest quality over a wide-range of metrics has been a goal toward which Community Care, UPMC Health Plan, and UPMC have long dedicated their efforts, including ensuring that members have adequate and timely access to behavioral health services.
We believe that ensuring such access requires concerted effort across five areas: (1) defining the criteria that are reliable and valid measures of adequate and timely access; (2) developing measures to accurately capture variability within chosen criteria; (3) training and educating individuals tasked with applying chosen measures to do so in a consistent and systematic manner that produces meaningful results; (4) identifying patterns, progress, and opportunities for improvements; and (5) targeting meaningful solutions and/or corrective action plans for those areas in which the need for improvement is identified. We have found that a problem in any of the aforementioned functional areas can render our best intentions to ensure adequate and timely access meaningless. Accordingly, through various internal initiatives as well as through stakeholder partnerships and collaboration, all of which are focused on outcomes, we systematically address all 5 requisite areas.
I’d like to talk a little bit about the steps we at Community Care and UPMC Health Plan have taken to implement best practices in each of these areas mentioned above. While the majority of my comments below will be provided from a payor perspective, many if not most are fundamentally applicable and relevant from a provider vantage as well.
Defining Criteria that are Representative of Timely and Adequate Acess
Most would agree that, insofar as healthcare delivery is concerned, adequate and timely access to services is a critical component of quality. If members cannot access a service, that service is of little or no use. In the context of access, however, “adequacy” and “timeliness” are relative terms that do not necessarily lend themselves to standard definitions, particularly in the behavioral health arena. Whereas a 24-hour access standard may seem like nothing short of overkill for most healthcare services, anything longer would simply not be sufficient in the face of potential lethality or other psychiatric emergency. As such, identifying timely and adequate access as a marker of quality is merely a first-step; establishing measurable standards necessarily follows.
Despite the relative nature of “timeliness” and the endless array of factors that impact this relativity, a failure to settle upon a measurable standard or to allow each unique circumstance to define or determine its own standard were not options for Community Care or UPMC; specific adequacy and timeliness standards had to be identified. To assist in this end, Community Care turned to other stakeholders, accrediting bodies (including NCQA and the Pennsylvania Department of Public Welfare), and existing statutory and regulatory requirements for guidance in setting appropriate timeliness benchmarks. Through these efforts and collaborations, Community Care has derived a comprehensive set of timeliness standards, beginning, for example, with a 24-hour telephonic triage and referral team assembled to assess members’ immediate needs and determine the most appropriate levels of intervention. Team members assist callers with emergent or urgent needs and ensure that provider visits are arranged as quickly as possible and always within the following timeframes: immediately for life-threatening emergencies; within one hour for non-life-threatening emergencies; and within 24 hours for urgent referrals.
While identifying these specific and/or mandatory timeframes as “quality-indicators” based upon objectively defined urgency standards is critical and important, Community Care recognized early in the process that members’ opinions of accessibility were equally important. While, for example, a 14-day timeframe within which to be seen for an evaluation has a certain appeal, it is equally (if not more) important to ascertain what members view as reasonable or adequate timeframes; members are our best barometers of what should be. As described in the section below, Community Care and UPMC developed a number of different means by which to capture such subjective input.
After identifying the timeframes within which it thought members should be seen and surveying members for additional input, Community Care considered the additional factors that could directly or indirectly impact adequate and timely access. It was important that Community Care and UPMC Health Plan as payors (and UPMC as a provider) not lose sight of the fact that timeframes are not met (or missed) in a vacuum. To the contrary, often a timeframe is little more than the consequence of competing variables. For Community Care these variables include things such as penetration rates, which identify the proportion of a member population who are actually utilizing services. The higher the penetration rate, the higher number of providers necessary to satisfy access standards. Additional variables include network adequacy, the member’s self-identified needs, the member’s clinical condition(s), and the array of available services. On the UPMC provider-side, variables such as staff-to-patient ratios and the type and range of staff employed are critical. Failing to recognize the interrelationship between these variables and timeliness could result in a failure to satisfy timeliness standards going forward; as such, a multi-dimensional assessment and approach to timely and adequate access is essential.
Measuring the Quality Metric “Timely and Adequate Access”
After identifying those standards and indicators that Community Care and UPMC Health Plan considered to be quality indicators with respect to timely and adequate access, it was necessary to develop valid and reliable means by which to measure and track those indicators. Community Care and UPMC Health Plan employ a number of different strategies to accomplish this end.
Community Care and UPMC Health Plan both include timeliness access standards within their respective network provider agreements; contracting entities are expected to maintain established timeframes or will be considered in breach of the agreement. Timeliness standards vary based upon urgency of care, i.e., emergent, urgent, and routine. Providers are additionally required to notify Community Care immediately when they are unable to accept new members into treatment. While contractually imposing these requirements may seem severe, Community Care and UPMC Health Plan believe that clearly delineating timeliness standards in advance is preferable to allowing contracting parties to be uncertain about amorphous standards.
Providers contracted with Community Care and UPMC Health Plan additionally agree to allow us to audit their compliance with these contractual requirements. Pursuant to these audit requirements, Community Care and UPMC Health Plan routinely audit contracting parties for compliance with these standards. Site visit surveys are conducted for non-licensed or non-accredited facilities (both at time of credentialing and at recredentialing), or whenever Community Care receives three or more site complaints within a 6-month period. If deficiencies are identified, quality improvement plans are required.
As set forth above, while auditing contractual compliance is an efficient means by which to measure the more objective timeliness standards imposed by Community Care and UPMC Health Plan, particularly those contractually required, Community Care/UPMC utilizes member satisfaction surveys to assess member sentiments in terms of timely and adequate access. Over the past few years, Community Care has seen an increase in member-reported satisfaction as to timely access (76.1% in 2008 to 78.2% in 2011).
Another means by which Community Care/UPMC tracks member satisfaction (or dissatisfaction) with access standards is via member complaints. Community Care, for the purposes of member complaints, defines dissatisfaction with access to services as “difficulty obtaining an appointment within a certain time period or within a certain distance, or the failure of a provider to meet the above required timeframes for providing a service.” In 2011, less than 1% of all Community Care complaints were related to access to services. During the same time period, UPMC Health Plan received no complaints related to access.
Given that timely access is impacted directly and indirectly by variables such as network adequacy, member need, and array of providers within provider network, Community Care tracks and measures these variables as well. Here again, Community Care relies upon requirements and benchmarks imposed by accrediting bodies such as NCQA and the Department of Public Welfare to serve as a guide to minimum sufficiency. For example, NCQA requires that Community Care contract with inpatient, residential, and ambulatory providers. As detailed more fully below, simply monitoring a timeliness standard alone would not be productive. Instead, Community Care carefully measures the sufficiency of and changes in the many ancillary factors that collectively result in or impact timeliness overall.
Training and Educating Those Measuring Access
Evaluating the success (or lack of success) of Community Care and UPMC Health Plan’s efforts to define and measure timely and adequate access standards could be undermined absent the comprehensive training, education, and outreach of all of those individuals tasked with measuring chosen criteria. It appears that this is one of the confounding factors experienced by the Veteran’s Administration despite its efforts to adequately track and monitor access.
Community Care/UPMC utilizes a broad array of means by which to make certain all stakeholders measure access in a consistent and standardized manner. Information about access requirements is included in both our provider manual and provider newsletters. We also routinely disseminate supplemental information during provider meetings and at any time upon request. All new providers are required to attend a comprehensive provider orientation, during which both the member access requirements and the means by which to capture and measure adherence are detailed.
Community Care uses its audit and site-visit process as yet another educational touch point with providers. Included in Community Care’s “Site Visit Tool” is a requirement to review the provider’s policy on appointment availability. Among the requirements are that (i) routine appointments are provided within 7 calendar days of request, (ii) life threatening emergencies are given immediate appointments; (iii) non-life threatening emergency are seen within 1 hour of contact; and (iv) members with urgent needs are seen within 24 hours of first contact. Community Care is of the mindset that the audit process is not a punitive process or a process aimed necessarily at identifying problems. Rather, it is valuable opportunity to share information and to work with providers toward understanding the myriad requirements facing them, including accurately and consistently tracking and measuring access.
In addition to educating providers on the standards expected of them, we inform members of what they can expect regarding access timeframes. We believe that members equipped with adequate information in this regard are in the best position to provide real-time, meaningful feedback as to how successful our providers and we are in meeting requisite standards. We rely on the member-complaint process as well as the care-management process for additional information regarding access performance. Furthermore, we routinely review triage and other referral calls to ensure access.
While adequately educating all stakeholders upfront is of critical importance, Community Care and UPMC Health Plan have learned that consistent monitoring thereafter cannot be overstated. A failure to reinforce the specific access requirements or the means by which to measure and track those requirements could weaken all of our efforts in these regards. As such, we employ a dedicated staff across multiple departments to accomplish these ends.
Analyzing Data Collected
The data gathered and maintained by Community Care and UPMC Health Plan is useful only to the extent that it tells us something about how we are performing with respect to access benchmarks. Here again, we engage a dedicated staff to analyze the information gathered via the myriad sources mentioned above. Such analyses are performed both for specific providers and sub-populations and for our collective provider networks; identifiable and aggregate reporting and analyses provide different but equally critical types of information. Where, for example, targeted information can inform us as to a given provider’s progress in meeting requisite benchmarks and serve as an indicator of compliance with contractual obligations, aggregate data provides insight into broader systemic trends.
As discussed above, our analyses are not limited merely to resultant timeliness. In addition, we routinely track and analyze provider sufficiency, both in terms of overall network capacity and within specific provider-types, such as psychiatrists or psychologists. We also closely monitor existing and anticipated member need (including diagnostic trends and condition prevalence) to anticipate and predict where added specialists may be required going forward. As discussed below, this information is then used for targeted contracting and/or hiring purposes.
Community Care and UPMC Health Plan track penetration rates to determine the rates at which members are accessing services. We believe that increased use, for example, of ambulatory and/or outpatient services ultimately contributes to decreasing the use of more restrictive levels of care. Generally, we have witnessed a trend toward increased penetration rates for less restrictive services. Over the past decade the percentage of dollars spent for inpatient services in Community Care’s behavioral health HealthChoices contracts has fallen from about 50% to just over 20%. In fact, when reviewing the results of the Community Care approach to care management, we have succeeding in significantly increasing overall number of users of service, while holding costs steady or even decreasing costs per member served.
Among Community Care’s routine reports is an “availability of providers” report, prepared by plotting the location of each member using address and zip code information and then comparing it to similarly plotted provider information. The resulting report shows the overall coverage for various provider types of service overlaid with the geographic location of our members. The report demonstrates the travel time for each member and then summarizes the precise percentage of members with access within the established drive time standards for each level of care. This information is used to enhance network development activities.
Our quality committees share analyses and results such as those described above both with targeted providers and with broader groups of stakeholders, including county administrators, accrediting bodies such as the Department of Public Welfare and NCQA, provider groups, and members. We believe strongly that, until this feedback is looped back to those providing, funding, and receiving care, it is of limited value.
Using Analyses to Prompt Change
While data for data’s sake may be interesting to some, its true value to Community Care and UPMC Health Plan is its usefulness in targeting necessary change and intervention. Over the years, data-analyses have prompted a wide range of change. These changes include traditional type of interventions such as targeted increases in certain types of providers, e.g., psychiatrists, as well as systematic planned development, such as increased funding dedicated to community-based services. If upon analyses, it is determined that timely access is only problematic within certain sub-specialties, Community Care may target its employment and/or contracting efforts to increase providers of this type. Hiring and/or contracting with more professionals, however, has been only one of many solutions implemented by us over time. A one-dimensional approach to change would be ineffective, particularly given the finite number of professionals in any given area, particularly in more rural regions. Moreover, records maintained by UPMC’s human resources department suggest that the time it takes to fill at least some behavioral health positions can be substantially longer than positions of other types.
Access feedback has also prompted Community Care/UPMC to explore and implement newer potentially revolutionary types of service-delivery, including telepsychiatry initiatives. Community Care now supports approximately 20 telepsychiatry sites throughout Pennsylvania using secure forms of video transmission. Psychiatrists working across locations within the same agency staff some sites. Other sites are staffed by UPMC psychiatrists who are supporting service providers in more rural parts of Pennsylvania. Community Care has tracked both provider and member satisfaction of these services with very positive results. Published research on telepsychiatry indicates that patient satisfaction is generally as high as with in-person services.
Mobile service delivery is another creative solution garnering increased interest by Community Care. Mobile therapy is particularly useful with those populations least likely to leave their homes to seek care, including the frail and elderly and individuals living in rural areas, as well as those whose behavioral health conditions render routine outpatient care difficult. An ample network is meaningless unless those persons who need services are able to access them. We have also worked with other stakeholders to substantially expand the range of services available to members. These additions include crisis services, hospital diversion programs, psychiatric rehabilitation, and certified peer services. All of these services have created new ways to access services and alternatives to traditional inpatient and outpatient models.
Community Care routinely works with a wide-range of stakeholders, including providers, county authorities, and members, in all implementation efforts. We feel strongly that collaboration is essential to sustainability.
Adequate and timely access to services is a critical component of quality. Ensuring access to services requires a sustained, systematic, and coordinated approach. We at Community Care, UPMC Health Plan, and UPMC believe that we have made great strides in these regards. I personally would like to thank you for the opportunity to discuss the work that we have done to improve access to services for members. I speak for Community Care and all UPMC affiliates when I offer any and all assistance that may be helpful going forward.