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In the eld of mental health and addiction
treatment, its hard to get people into
treatment in the rst place,
harder to get them well, and
harder still to get them to a
place where their mental
health or addiction problem
can be considered resolved.
A new program launched
in 2008 in Minnesota is
drawing regional and even
national praise from mental
health practitioners and
primary care providers for
data-driven results. Health
plans are even climbing on
board.
The so-called Diamond
program, created and
sustained by ICSI, the
Institute for Clinical
Systems Improvement, in
Bloomington, Minn., combines
an evidence-based standard of
care for treating depressed persons with a
bundled payment to physician practices to
cover their extra costs in managing the
program.
An integrated depression care management
program, Diamond is supported by nine
Minnesota health plans. It provides a common
payment code for collaborative care, and has
been introduced at 83 primary-care clinic sites
over the past two-and-a half years. It is part of
Minnesotas state medical home model. Most
important, it is yielding strong
clinical results.
The program and the
processes work pretty well, in
terms of its goals of getting
better care for depressed
patients, said Timothy
Hernandez, M.D. medical
director for Family Health
Services Minnesota, a mid-
sized medical group in St. Paul.
This is a good model, said
Mark Williams, M.D., a
psychiatrist at the Mayo Clinic.
Its more effective than other
conventional programs.
In the state of Minnesota, the
average depression patient gets
into remission, or a depression-
free state, only 4% or 5% of the
time, he said. In our (Mayo)
clinics, when we add the
Diamond program, we see many more
patients getting into remission. Weve gotten
results in the 20% to 40% range.
Depression, said Nancy Jaeckels, who
developed the program for ICSI, is the most
prevalent disorder of the conditions that cause
loss of working time in the U.S. work force. It
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October 5
September 14-16
Calendar
2 Aug 2011
August 23-25
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E-Mail
info@payersandproviders.com with
the details of your event, or call
(877) 248-2360, ext. 3. It will be
published in the Calendar section,
space permitting.
www.lakesidecommunityhealthcare.com
Midwest Edition
Minnesota Tackles Depression
Diamond program Pays Doctors to Improve Care
Continued on Next Page
Nancy Jaeckels,
ICSI Vice President
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19144
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Payers & Providers Page 2
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In Brief
Northern Michigan
Enters Talks With
McLaren Healthcare
Northern Michigan Regional Health
System in Petoskey is exploring a
strategic partnership with McLaren
Healthcare, of Flint, the hospital
groups announced in late July. They
have signed a letter of intent to
exclusively and condentially
negotiate an afliation over the next
four months.
Reezie DeVet, president and CEO
of Northern Michigan, said an
afliation would give her hospital
economies of scale for purchasing,
better borrowing terms and access to
capital, shared clinical expertise, and
more operating efciencies and better
access to care.
DeVet said an alliance with
McLaren would preserve local control
for the Petoskey hospital. It would also
include possible participation in
McLarens insurance division, which
involves a Medicaid product and an
HMO useful linkages in the time of
health reform. McLaren had revenues
of more than $4 billion in 2010.
Northern Michigan had previously
been considering an afliation with
Spectrum Health, based in Grand
Rapids, but those talks fell apart in July
2010.
Three Men Indicted
In Home Health
Fraud near Chicago
Three men involved in a home-health
business in south suburban Chicago
were charged in a Medicare fraud case
in late July.
Bahir Haj Khalil, manager and co-
owner of House Call Physicians LLC in
Palos Hills, Ill., and Paschal U.
Oparah, 46, a podiatrist whose license
had been suspended, were charged
with one count of healthcare fraud.
Mohammed Khamis Rashed, 45, also
Continued on Page 3
NEWS
Diamond for Depression (Continued from Page One)
has a direct relation to increasing absenteeism
and decreasing productivity, and costs U.S.
employers many billions of dollars each year.
In Minnesota, a depressed employee costs
employers $3,000 to $4,000 a year.
Now that mental health has payment parity
with physical health, medical homes and
accountable care organizations will quickly
learn that people with multiple medical
conditions are persons with mental health or
substance abuse disorders are the two
populations critical to getting a handle on U.S.
healthcare expenditures, she said.
The Diamond model uses a consistent
method for assessment and monitoring: the
PHQ9 assessment, a short questionnaire that
gauges the severity of depression. It has ranges
relating to mild depression, moderate
depression, or severe depression, which
translate to treatment options and frequency of
intervention. Today, about 8,000 Minnesotans
are actively enrolled through Diamond.
Primary-care practices that want to
participate and receive compensation must be
Diamond-certied. In our state, Jaeckels
said, for commercial payers to give that
payment, they want to make sure medical
groups are trained and have systems and staff
in place to implement this model. They have
to go through a six-month training program
that explains how to alter their ofce systems,
use the assessment tool, develop a patient
registry, and apply a team approach instead of
a physician-centered go-it-alone approach.
Those start-up costs average about $37,000
per medical practice.
The start-up costs arent compensated, but
once the practice is certied, health plans will
pay providers a certain amount per Diamond-
enrolled patient per month to cover the
additional care management expenses. Those
expenses include a dedicated care manager, a
consulting psychiatrist, extra costs for billing
and coding, for patient registry and IT systems,
and supervision of the Diamond program.
Those costs add up to roughly $109 per
patient per month. Each health plan and
provider group negotiate their own payment
amount.
Patrick Courneya, M.D., medical director
for HealthPartners, the large Minnesota
integrated managed-care provider, said the
program is working well for both providers
and health plans. In his personal experience
as a physician, the care managers have been
effective in engaging physicians and other
providers, including the consulting
psychiatrist, and linking them all together for
the benet of the individual patient.
As providers we have gotten into the habit
of making those referrals as a standard of our
care, Courneya said. We get consistently
positive feedback from our patients, too. The
health plan, as a result, is willing to pay the
extra fee. Weve done that to put some
nancial backing behind this idea of trans-
formation of the care model.
Some providers see side benets beyond
the extra payment. For our clinic and system,
this was the rst foray into team care,
Hernandez said. This cultural shift has taken
some time to get used to. Were not trained
that way in medical school and residency, and
were not used to working with our specialists
in such a style, he added. Usually we send
him a patient and they send them back.
Letting a care manager take charge of the
patient sometimes feels like were abdicating
our own responsibilities, and now were
asking them to do it, he said. Still, when the
practice introduced the program, it felt like it
would be a good entre to medical home.
There have been numerous attempts by
healthcare quality entities, such as the
Institute for Healthcare Improvement, to
move the dial on treatment of depression.
What makes Diamond distinctive, said
Williams, is two things: First, a payment
model where you can get reimbursed. Second,
they have a reporting structure, so you know
how you can compare with other places that
have some of the same challenges you do.
The Diamond model is based on the
Impact study of 1998, a large-scale depression
research project at the University of
Washington. Under the care model developed
through Impact, we doubled the likelihood
that patients depression improved, said
Juergen Unutzer, M.D., a psychiatrist and
principal investigator of the project. We
found they had better physical and social and
work related functioning. We also found that
those patients in the impact program had
much lower healthcare costs four years later.
Diamond, he said, is one of the larger-
scaled implementations of this model, among
a large number of states and localities
adopting it.
One of those is in Grand Rapids. There,
Steve Williams is leading an effort to
replicate what ICSI has done among health
plans and employers in western Michigan.
We hope we will able to adopt Diamond
intact. Then were just assembling our payers
to develop a payment methodology.

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Page 3
Payers & Providers
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NEWS
In Brief
co-owner of House Call, was charged
with one count of visa fraud, as was
Khalil.
Charges were led by the U.S.
Attorneys Ofce in Chicago, through
the Medicare Fraud Task Force. The
investigation was part of the Health
Care Fraud Prevention & Enforcement
Action Team (HEAT) a joint effort
between the Justice Department and
the Health and Human Services
Department.
The healthcare fraud involved
billing for services as though they
were done by physicians, when they
were actually done by physician
assistants, and certifying that patients
were homebound, when they were
not. Under the visa fraud scheme,
Khalil and Rashed allegedly tried to
get a work visa for Khalil to work in
the U.S. by stating that Khalil was not
already employed and did not own
House Call and that the business was
going to hire him as a home health
aide making $8.50 an hour. Khalil, 33,
a native of Syria and citizen of
Canada, was not authorized to work
in the U.S.
Between 2008 and May 2011,
Medicare reimbursed House Call for
more than $3.3 million, based on
36,864 claims for 2,348 beneciaries.
Judge Blocks Kansas
Law Banning Medicaid
to Planned Parenthood
A federal judge ruled Aug. 1 that a
Kansas law effectively prohibiting
Planned Parenthood from
participating in Medicaid is likely
unconstitutional.
U.S. District Judge J. Thomas
Marten granted the family planning
agency a temporary injunction to halt
enforcement of the law. The agency
said without the injunction, it would
have had to close its ofce Hays, a
remote town in western Kansas that
serves 5,700 patients.
Marten said the law probably
violates federal rules that prohibit
extra restrictions on a federally
nanced program. He said he thought
the law was intended to punish
Planned Parenthood for providing
abortions.
An earnings report by the countrys largest for-
prot hospital operator may presage a
downward trend in the revenue that hospitals
derive from surgeries.
HCA, based in Nashville, reported lower
than expected earnings on July 25, in part
because of a decline in expensive surgical
procedures.
While the company had favorable
admissions growth during the quarter, we
experienced a shift in service mix from more
complex surgical cases to less acute medical
cases. This resulted in lower than anticipated
revenue growth and earnings, said Richard
M. Bracken, HCAs board chairman and CEO.
Admissions for surgeries declined 1.6%,
while medical admissions rose 3.7% in the
second quarter. Same facility equivalent
admissions rose 1.9% and emergency room
visits increased 4.5%. Cash revenue per
equivalent admission rose 1.1%. Per patient
income from Medicare also declined.
Analysts wondered whether the move
away from complex surgical cases was
attributable solely to issues related to HCA, or
whether it signaled a larger change in the
environment for health care operators.
HCA shares fell 19% the day of the
earnings announcement, when it reported
second-quarter nancial results that didnt
match analysts estimates.
HCA, which had been privately held since
a leveraged buyout in 2006, went public with
an initial public offering in March this year.
HCA operated 164 hospitals and 111 surgery
centers at the end of June.
The United States will spend 19.8% of gross
domestic product on healthcare by 2020,
according to a new analysis published in
Health Affairs.
Annual growth in health spending from
2009 through 2020 will average 5.8%, or 1.1%
faster than growth in the general economy. The
Affordable Care Act will account for an extra
0.1% of that, the authors said. The article said
the health reform law will allow 30 million
people to get health insurance by that year.
We are projecting a decline in the out-of-
pocket share (for patients), but that doesnt
mean that the consumers burden is going to be
substantially reduced, said Sean Keehan, an
actuary at the Centers for Medicare and
Medicaid Services and lead author of the
article. Especially since were projecting
health spending to grow at a faster rate than
economic growth and disposable personal
income.
In 2014, the year the new law goes fully
into effect, national health spending growth is
expected to hit 8.3%. In 2010, by contrast, it
was 3.9%, the lowest in recent years, because
of the recession.
Robust growth in Medicare enrollment,
expanded Medicaid coverage, and premium
and cost-sharing subsidies for exchange plans
are projected to increase the federal
government share of health spending from
27% in 2009 to 31% by 2020, the authors
said. The article can be found at
www.HealthAffairs.org.
Health Spending to Hit 19.8% in 2020
CMS Sees Growth Rate at Average 5.8% per Year
HEALTHCARES BEST ADVERTISING VALUE
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PAYERS & PROVIDERS reaches 5,000 hospital, health plan and non-
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HCA Reports Decline in Surgeries
Fewer Complex Procedures Hurt Financial Results
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Payers & Providers Page 4
The patient care delivery systems of the future
will be signicantly inuenced by the industry
trends that are impacting the healthcare
industry today. Evolving payment and care
delivery models (e.g., clinical integration,
patient-centered medical homes) will test an
organizations ability to manage costs and
demonstrate quality. Hospitals will
continue to consolidate to enhance their
market and nancial strength. Post-acute
providers, medical groups, and independent
practice associations will seek to explore new
relationships with acute care hospitals.
Additionally, physicians will
continue to look for
employment through
hospitals or in large medical
group practices.
Given the complex issues facing the
healthcare industry, the nurse executives role
will by necessity emphasize collaboration with
all providers to operationalize the
organizational changes required in the future.
Here are the six healthcare trends impacting
nursing.
Development of alternative methods of
care. Patient care will need to evolve at a
rapid pace to maximize out-of-hospital care.
This will mean that physicians, nurses, and
professional service providers, such as
physical therapy and pharmacy, must partner
in delivering ambulatory and home care.
Technology will play a larger role in
monitoring and successfully managing patients
in their homes.
Focus on cost management. Cost
management will be the key to hospital
survival, which will impact all aspects of the
operations, including workforce compensation
and resource utilization. Nurse leaders will
have a pivotal role with physicians and mid-
level providers to perfect care protocols and to
standardize care approaches.
Evolving new care models. Healthcare
organizations of the future will require a
system approach that involves all disciplines of
the healthcare team. Delivery models will
focus on the continuum of care with a
particular emphasis on chronic disease
management and patient education and
engagement. Staff must practice to the top of
their licensure and utilize multi-disciplinary care
teams in inpatient settings, post-acute services,
and outpatient settings. The complexity of care
delivery of the future will require an advanced
clinicians education credentials to master
critical thinking skills and adopt advanced
technology, as well as address the
communication and coordination challenges.
Transparency and account-ability. Health
systems must organize care delivery that is
patient-centered and in compliance with
evidence-based standards.
The ability to reduce
variability in patient
outcomes will be reected in
a reduction in cost per case,
an increase in market share, and the ability to
recruit and retain excellent clinicians.
Dashboard or scorecard documentation of
current practice outcomes compared to targeted
goals will increase the teams accountability for
better patient outcomes.
Continued focus on patient safety and
quality outcomes. As consumers are becoming
increas-ingly informed, they will make
healthcare choices based on publicly reported
data. Nurse-sensitive indicators such as patient
falls and injuries, hospital-acquired infections,
pressure ulcer prevalence, failure to rescue, and
restraint prevalence will start to factor into
patient choice.
Creating standards of practice. Health sys-
tems will continue to merge with other systems
and acquire hospitals. The nurse executives of
these entities have the challenge of creating
common standards of practice through policy
development, clinical documentation, human
resources practices, staff orientation and edu-
cation, and stafng practices, to name a few.
OPINION
Nurse Executives Role is Growing
They Have the Skillset to Deliver Accountable Care
Patricia Hines and Bonnie Barndt-Maglio are
PhD nursing experts who consult with The
Camden Group. Reach them at
PHines@thecamdengroup.com or Barndt-
Maglio@thecamdengroup.com.
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By Patricia Hines
and Bonnie Barndt-Maglio
!!!"#$$!%&!'(&)*+!,!'*-./0)*+!'1%2/+3/456!778
MARKETPLACE/EMPLOYMENT
Page 5 Payers & Providers


luyors & lrovdors und MCCL prosont koundtubo lntoructvo. lt dobuts Murch 20|| n tho luyors & lrovdors Nutonu odton.
Cur roudors uvuys vunt to knov vhut s on tho mnds ol houthcuro's c-suto oxocutvos. Conloroncos und trudo ovonts olton
ony uov lor crucu momonts to ntoruct vth thoso thought oudors. \th koundtubo lntoructvo, you' cut through tho
promnuros und mmodutoy knov vhut's on thor mnd.
Lvory koundtubo lntoructvo v louturo u C&A sosson conductod by luyors & lrovdors lubshor kon Shnkmun. Hs
docudos ol oxporonco n ournusm und tho houthcuro ndustry v promso concso und rovoung ntorvovs.
1opcs lor upcomng koundtubo lntoructvos ncudo:
!! lntogrutod Systoms vs. lrvuto lructco: 1o vhut dogroo v physcuns not uroudy n urgor modcu groups or ntogrutod
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houth puns und systoms try to ncrouso shuro und concontruton n ths murkot:
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ncuson:
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*New England Journal of Medicine, 2004.
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Payers & Providers
MARKETPLACE/EMPLOYMENT
Page 6
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