It’s 11:30 on a Tuesday night in the emergency department of a local county hospital. The doctor pulls back the curtain on his next patient and frowns. He has seen this man before. He looks down at the chart and recognizes the name. He’d been in about eight weeks before with trouble breathing and chest pains. Gears click in doctor’s memory, as he recalls this patient. His medical work-up had shown nothing acutely wrong. He’d been encouraged to take his usual medications, and sent home with instructions to see his regular doctor as soon as possible to make sure his chronic diabetes and congestive heart failure were under good control.

The doctor pulls a stool across the floor and sits down bedside.

“Hi Brian, what seems to be the trouble?”

“My chest. I couldn’t breathe. And I can’t seem to concentrate. I just don’t want to do anything.” Brian’s voice is listless and low, and he looks fatigued.

“I see you were in a couple of months ago. Did you go and see your regular physician?”

Brian shrugs but doesn’t say anything. His eyes are fixed firmly on the floor.

The doctor pauses. He looks at Brian for a while. The man looks like he hasn’t taken care of himself. His clothes are wrinkled, and he’s lost some weight since his last visit to the emergency department. The doctor looks over Brian’s vitals and labs. He finds nothing concerning on physical exam. He asks, “Brian, has anyone ever talked to you about depression?”

In the case above, Brian is a fictional character, but the situation is not. The co-occurrence of mental health disorders with physical ailments is common. A Substance Abuse and Mental Health Services Administration (SAMHSA) report found that 68 percent of adults with mental disorders have medical conditions, and 29 percent of adults with medical conditions have mental disorders. The most common of these is depression. Many research studies have found high rates of comorbid depression with chronic and terminal medical conditions. In many cases, the medical conditions or treatments for the conditions can cause depression. In others, the depression itself can lead to health behaviors that cause or worsen medical illness, and even higher risk of death. For instance, persons with depression have higher rates of smoking cigarettes than the general public. This can lead to heart disease. But, depression itself can also cause changes in brain chemistry and platelets, which can worsen existing heart disease.

Common Conditions with Comorbid Depression

Comorbid depression in some medical conditions is common. According to the National Institute of Health, there is a close relationship between depression and other physical ailments:

• Alzheimer’s disease and other dementias
• Cancer
• Coronary artery disease
• Congestive heart failure
• Diabetes
• Epilepsy
• HIV/AIDS
• Multiple sclerosis
• Parkinson’s disease
• Rheumatoid arthritis
• Stroke
• Systemic lupus erythematosus

Depression also has a negative effect on treatment and outcomes for these diseases. A 2015 published research study showed those with comorbid depression had more negative outcomes for their primary ailment than those who only had the primary ailment. Research also shows a lower quality of life, lower compliance with medical treatments, and lower rates of exercise and healthy eating habits for patients with comorbid depression compared to those with the same physical ailment(s) who did not suffer from depression.

This comorbidity has consequences beyond the health of the patient. People with multiple medical conditions are a rapidly growing and extremely costly segment of the US population. Patients with behavioral health disorders spend more on treatment for general medical conditions. When compared to those without depression, overall health care spending for medical conditions is higher than those without, in addition to treatment for the depression itself.

Improving Care for Comorbid Behavioral Health Conditions

The first step is identifying patients with comorbid behavioral health conditions before they reach the dangerous and costly levels discussed above. The primary care setting may be the best place to first find depression. But how?

Magellan’s Screen and Engage program is an innovative, user-friendly application that primary care physicians (PCPs) can use to identify patients at risk for a mental illness. Using a Magellan-provided iPad, the patient answers questions about his or her health and well-being while waiting for an appointment. The screening tools are also available in Magellan’s Virtual Care Solutions. Magellan’s proprietary algorithms assess the results, identify potential behavioral health issues and suggest recommendations for treatment, and flag clinicians to engage the patients.

The benefits of the tool are clear. Given the limited amount of time that a PCP has for each appointment, he or she must focus the conversation on the primary reason for the visit. As such, there is little opportunity to probe for behavioral health concerns. By conducting the screening before the short appointment, the PCP has a chance to be notified of the screening results, and discuss them during the visit.

Screening for behavioral health conditions is just the first step. Step two is treating them. In general, depression is treated with either medications and/or cognitive behavioral (CBT) psychotherapy. CBT is a specific type of therapy that relies on identifying and changing ones thoughts that can lead to depression. Research shows that the combination of the two is better than either done separately. While it may be easy to receive anti-depressants from medical doctors, it is often difficult to find CBT.

Cobalt, Magellan’s computerized Cognitive Behavioral Therapy (CCBT) program, is a cost-effective solution to address common behavioral health conditions. Cobalt provides CCBT online or through a smartphone/tablet app. This makes face-to-face CBT—proven to work but often difficult to find providers, especially in rural areas and for working people—available anywhere, any time. It is also a more private approach to CBT. Patients can access treatment from their homes versus an office.

Computerized CBT has proven to be just as effective as in-person CBT. Magellan offers Cobalt modules for insomnia, depression, anxiety, substance use disorder and obsessive-compulsive disorder, treating more than 90 percent of behavioral health conditions seen in primary care and behavioral settings.

Tackling Comorbid Conditions for a Healthy Future

At Magellan, we have made it our mission to help individuals like Brian, whose case is all too common. Tackling comorbid behavioral health issues alongside common medical conditions is one way we do it. Investing in and using new technology, we can identify more people who need help and expand their access to effective, proven treatments.

When I was selected to join the National Quality Forum’s Medicaid Innovation Accelerator Project Coordinating Committee, I thought about the background and experiences I would bring with me – both personally and professionally. As a trained pediatrician, my medical training focused largely on the care and treatment of young children. According to the Centers for Medicare & Medicaid Services (CMS), more than 45.2 million children were “ever-enrolled”¹ in Medicaid and the Children’s Health Insurance Program (CHIP) during fiscal year 2015. In addition, in the time since I was in practice, I’ve worked for several national healthcare companies, with a focus on population health, clinical delivery systems delivery and improvement.

Since joining Magellan as the company’s chief medical officer, I’ve worked with my colleagues to help continually looks for ways to reinvent how care is delivered. I am passionate about supporting the volume-to-value payment transformation, and Magellan has a key role to play because of the deep expertise we bring in behavioral health. Oftentimes, we don’t realize how specialized and important that expertise is, and how it impacts the overall quality of care for a patient, particularly with comorbid conditions. Magellan is also considered a trusted partner because we are an independent company and not part of a big health plan. In addition, we also bring a breadth of experience in medical specialty, medical pharmacy and long-term services and supports (LTSS) which is not found in most other organizations.

NQF’s Medicaid Innovation Accelerator Project (IAP) Coordinating Committee is tasked with identifying and recommending measures in four priority areas to help support states’ efforts related to payment and delivery system reforms.

The four priority areas are:

• Reducing Substance Use Disorders (SUD)
• Improving Care for Medicaid Beneficiaries with Complex Care Needs and High Costs (BCN)
• Promoting Community Integration – Community-Based Long-Term Services and Supports (CI-LTSS)
• Supporting Physical and Mental Health Integration (PMH)

The challenges – and opportunities – are many. Medicaid behavioral health does not currently have standard benefit packages from state-to-state, and there are also not standard billing practices. Both of those elements make it much harder to develop metrics which are reliable, and more technical expertise is needed to ensure that the metrics selected can be broadly used. Ultimately, this committee will provide guidance on performance measures for areas which are unique to Medicaid, including patients with complex health needs, LTSS needs and those with behavioral health and substance use/opioid disorders. The states will then have a list of standardized measures for use in Medicaid performance program evaluation.

All of the committee’s meetings are open to the public. The IAP will issue its draft report in July, and its final report at the end of September. I look forward to working with my committee colleagues as we work to draft these important metrics related to state’s efforts regarding payment and delivery system reforms.

¹These enrollment data are unduplicated counts of children who were enrolled in Medicaid and CHIP at any point in FFY 2015. A child who was enrolled in more than one program (e.g., Separate CHIP and Medicaid) at different times during the FFY is only counted in the program in which he or she was last enrolled.

In late January, Magellan held its second annual Magellan Open Vision Exchange (MOVE) conference in Scottsdale, Ariz. MOVE brings together a large cast of voices from the healthcare industry to discuss the future of healthcare for patients, plans and providers. Over two days, we heard from private industry experts, government leaders, as well as other subject matter experts and thought leaders both from inside and outside the healthcare industry.

The Future of Healthcare Beyond the Affordable Care Act

Obviously, the continuing debate over the future of healthcare and the Affordable Care Act were a central topic of the conversation at this year’s MOVE. A number of speakers talked about the impact of the Trump Administration’s efforts to repeal the Affordable Care Act. Former Utah Governor Michael Leavitt, who also served as the secretary of the Department of Health and Human Services, said that while he expects repeal and replace legislation will pass, significant parts will be deferred for three or four years. Brian Coyne, VP of federal affairs at Magellan Health, said that he feared gridlock over the next couple of years.

Managing Transformation in the Healthcare World

One of the key topics discussed at this year’s event was the immediate future of the healthcare industry. After a long period of explosive innovation, there was consensus that disruptive change will continue. Magellan Healthcare CEO Sam Srivastava posited that we are currently in a tech-bubble that is about to burst. The industry is waiting to see which of the early healthcare technology entrants will survive and how technology and healthcare will continue to interface with each other.
Leavitt spoke extensively of the need to manage transformation, especially in healthcare. Leavitt stressed that systematic healthcare change takes hold over three to four decade cycle, and he believes we are less than mid-way through the current transformation. Using an analogy of a cattle herd, Leavitt made the point that you can’t drive a herd too quickly, or you risk a stampede. You also can’t push the herd too slowly or it will meander. Applied to healthcare, the idea is simple but true: If we push change too quickly there will be chaos, but if we fail to adapt and change, we will stagnate. Allowing ourselves to be “lulled into inaction” is a recipe for disaster.

Value-Based Healthcare

A critical area of discussion was the expansion of value-based care. Speakers agreed that demand for value-based care is accelerating. Leavitt said he believed this was true regardless of the Trump Administration’s plans for healthcare. Billy Millwee, President and CEO of BM&A Public Policy, cited broad bipartisan support for the value-based model and agreed that it was here to stay.

Chet Burrell, president and CEO of CareFirst BlueCross BlueShield, spoke clearly on the approach that his company was taking: “We started and ended with common sense.” He went on to explain that they had built their model with the primary care physician at the center (PCP). The PCP knows the patient best and is therefore in the best position to make decisions regarding who to refer and to whom. By taking this approach, Burrell relayed, CareFirst was able to build a patient centered medical home model that improved care while reducing costs.

Despite the level of change being experienced throughout healthcare, a common theme was one of our industry being grounded in helping people get the high-quality care they need, affordably. This is the essence of why healthcare is our chosen industry and why we are driven to innovate.

An interesting takeaway was that across the conference and speakers, there was a clear common theme: while the ultimate structure of the pay-for-value transformation is uncertain, the movement will continue. Experimentation, promoted by both public and private payer initiatives, will drive innovation and change. Some will be better prepared than others to handle this paradigm shift.

According to the Kim Foundation, one out of four Americans experiences behavioral health issues. Of those, 60 percent are not receiving treatment.

Why are so many people not receiving treatment?

What does this mean for providers?

What more can be done to increase access to behavioral healthcare?

Learn more about this issue by downloading Magellan’s new infographic, “Mind the Gap: Increasing Access to Behavioral Healthcare.”

Millions of people are challenged by drug and/or alcohol use, which may result in physical and emotional health concerns. Many individuals feel like they have lost control and struggle with depressive signs and symptoms, in addition to substance use – and only a fraction of these individuals receive care, according to a report on addiction released in November by the U.S. Surgeon General.

At Magellan Health, our clinical methodology for the management of substance use incorporates leading principles of care, involving appropriate assessment, evidence-based interventions, as well as close collaboration with other healthcare providers who are vital to the delivery of effective care. At the core of Magellan’s interventions for substance use is our suite of computerized cognitive behavioral therapy (CCBT) programs powered by Cobalt Therapeutics, as well as screening software, and optional wraparound telephonic support.

Magellan’s Cobalt platform includes online, well-studied programs proven to help individuals who are coping with various behavioral health conditions. Among our Cobalt CCBT programs is SHADE – a 10 session mobile and web-based program for individuals living with alcohol, and/or drug use and co-morbid depression. SHADE provides skills-building exercises, which include mood monitoring, problem brainstorming, pros and cons analysis, planning for change, identifying problematic thought patterns and developing effective drug refusal skills. SHADE helps participants control their substance use, alcohol use and low mood by promoting long-lasting skill-based changes in behavior and thinking.

Published in the journal Addiction, SHADE has been proven in randomized, controlled trials to:

• Be comparable in efficacy to face-to-face therapy.
• Reduce hazardous drug and alcohol use by 44-58 percent after 6 months.
• Reduce hazardous use by 72 percent after 12 months.
• Significantly reduced binge drinking.

SHADE was listed favorably among the technology assisted interventions highlighted by the surgeon general’s report as a tool designed to “(1) increase access to care in underserved areas and settings; (2) free up time so that service providers can care for more clients; (3) provide alternative care options for individuals hesitant to seek in-person treatment; (4) increase the chances that interventions will be delivered as they were designed and intended to be delivered; and (5) decrease costs” (see https://addiction.surgeongeneral.gov/ for more information).

You can learn more about Magellan’s Cobalt CCBT capabilities here:

Magellan’s self-guided Computerized Cognitive Behavioral Therapy from Magellan Health on Vimeo.

Opioid addiction kills thousands of people every year. In 2014, for example:

• There were 18,893 overdose deaths related to prescription painkillers
• There were 10,574 overdose deaths related to heroin

Despite these shocking numbers, the problem continues to grow. (It quadrupled in the first decade of this century and continues to explode). In the past twelve months, the Drug Enforcement Administration (DEA) has been forced to issue new warnings on drugs such as fentanyl, a potent opioid more than 100 times more powerful than morphine and 30-50 times stronger than heroin. While fentanyl has killed thousands of people over the past few years, many only heard of it recently, when it was attributed to the death of the musician Prince.

Close to Home: Opioid Addiction from Prescription Sources

Given the dangerous nature of some of the most common prescription painkillers—not just from concerns about addiction but from accidental and intentional overdose (the leading cause of accidental death)—it may be surprising to find out just how common it is to find opioid medications in the home.

In 2012, the Centers for Disease Control (CDC) calculated that healthcare providers wrote 259 million prescriptions for opioid painkillers. That is enough for every American adult to receive a bottle of pills.

While there have been efforts to reduce the number of prescriptions written, the number of prescriptions remains very high and the volume of opioid medications already distributed is also alarming.

And this is a key contributor to the opioid addiction crisis. According to the CDC, most people who abuse prescription opioids get them for free from a friend or relative. Essentially, people give their old prescribed medications to friends or relatives. Or, alternatively, abusers take old prescription pills from friends and relatives without their knowledge.

Even among the people at the highest risk of overdose (using prescription opioids non-medically 200 or more days a year) a friend or relative’s medicine cabinet is a common source of finding opioid medications. Among that population:

• 27 percent use their own prescriptions;
• 26 percent get them for free from family or friends;
• 23 percent buy them from friends or relatives; and
• 15 percent buy them from drug dealers.

Cleaning Up: Reducing the Availability of Prescription Opioids

Since the early years of the decade, state and federal authorities have made a concerted effort to reduce the regularity by which opioid medications are being prescribed. In particular, there has been a focus on reducing the ability of abusers to use multiple prescribers to issue painkillers.

Several states have achieved various degrees of success. In New York, the number of patients seeing multiple prescribers for painkillers was reduced 75% percent between 2012 and 2013 after prescribers were required to check the state’s prescription drug monitoring program before issuing a prescription.

In the same time-frame, Tennessee saw a 36 percent reduction in the number of patients seeing multiple prescribers for painkillers when it instituted a program similar to New York’s.

Florida saw a 50 percent reduction in oxycodone overdose deaths between 2010 and 2012 after it regulated painkillers and stopped providers from issuing painkillers from their offices.

In addition to programs aimed at healthcare providers, the Federal government has directed resources towards educating consumers about disposing prescription opioids and other medications. The Food and Drug Administration provides information on the safe disposal of painkillers such as Fentanyl patches. The Drug Enforcement Administration is also providing information for the public regarding disposal as well as created a program to authorize and register drug disposal collectors.

A Pioneer in Substance Use Management

Magellan Health is a pioneer in offering integrated, comprehensive opioid risk and substance use management programs. We have an unyielding commitment to ending the current epidemic. And we are uniquely positioned to bring together behavioral, medical and pharmaceutical programs to positively impact overall population health and reduce cost.

Opioid addiction has grown over the past fifteen years from a personal issue to a national emergency. A new infographic from Magellan Healthcare reveals the devastation that this epidemic is causing.

• In 2014, there were 18,893 overdose deaths related to prescription pain relievers
• There was a 3,203% rise insurance claims for opioid dependence diagnosis from 2007-2014
• Prescription opioid abuse is costing employers $25,000,0000 a year

The opioid addiction crisis is causing such an unprecedented amount of harm precisely because it is such a complex, multi-faceted issue. Those looking for answers as to how such an epidemic could have happened, will need to examine a swath of individual problems, including:

• The enormous quantity of prescription opiates
• The limited patient knowledge of opiate risk
• That diversion of opiates to family and friends is so common that only 20% of those with opioid abuse problems are actually using opioids prescribed to them
• The struggle to adequately assess patient’s substance use history and risk of addiction when prescribing opiates
• The lack of clear guidance as to who should receive opiates and for how long
• The difficulty in maintaining patient adherence to withdrawal management treatment plans.

New solutions are needed to tackle each of these individual issues. At Magellan Health, we intend to do precisely that. The opioid addiction crisis has already taken a huge toll and it grows worse every day. It is manifesting itself in myriad ways among thousands of communities across the nation. At Magellan Health, we have an unyielding commitment to ending this epidemic.

Written by Thomas Lane, NCPS, CRPS

What’s in a word? Much more than many of us realize.

In the context of behavioral health, substance use and even physical health challenges, using terms and phrases that group people by diagnosis, disability, disease and other characteristics perpetuates stigma, discrimination and exclusion. Yet this type of language has been part of the healthcare lexicon for decades. Outdated terms such as “addict,” “crazy” or “diabetic” are just a few common examples.

We live in a time when individuals are at the center of the healthcare field. As healthcare consumers, individuals are empowered to make their own health choices. As healthcare professionals and activists, we need to mirror this empowerment, and seize the opportunity to pivot how we portray what we do. We need to move away from archaic language that contradicts all of the positive changes we help individuals make in their lives on a daily basis.

This is where “person-first language” can make a big difference.

What is person-first language?

Person-first language means seeing people as “people first,” and not as their disease, illness or disability, or as part of a homogeneous group. It portrays individuals living with behavioral health, substance use or physical health challenges beyond a lens of illness, diagnosis and hopelessness. It helps address issues relating to illness-identity and self-stigma, keeping in mind that we are all unique individuals, with unique lived experiences.

At Magellan Health, our use of person-first language stems from our work in behavioral health, but it applies to everything we do with equal emphasis. It shows our commitment to being culturally and linguistically appropriate in all of our communications. It models our principles of recovery and resiliency, and contributes to evolving and improving our organizational culture.

On a personal level, as an individual in recovery myself I can tell you how important person-first language became to me as I discovered the often unintended consequences of using language that robs one of their individuality. We all deserve respect and appreciation for our unique qualities.

How is person-first language used?

Using person-first language is an intentional practice. Here are some examples of old language that is commonly used in comparison to newer, person-centered language that can be applied by anyone:

• From “chronic disease management” to “improving health outcomes for people living with chronic health conditions.”
• From “illness self-management” to “improving health education, support and community inclusion to promote individual wellness and self-direction.”
• From “crazy, nuts, lunatic” to “someone who may benefit from services and supports.”
• From “individuals suffering with a mental illness” to “individuals with a mental illness.”

For practice, try to recognize when others use the outdated or inappropriate terms and phrases above. And ask yourself how often you use them. Then, make the conscious choice to omit them from your vocabulary and replace them with new terms. While changing an old habit can be a challenge, consciously developing a new one is an easier path to meaningful change.

Remember, we all have choices about the words we speak and write. Those choices can either affirm the distinctive individuals that we are — or diminish us with labels. The words we use can fill us with hope, or burden us with despair. So let’s choose hope.

Changing the way you speak and write is a gradual process. But by putting the person first when you do, you can play a role in bringing our healthcare language into the 21^st century.

For more information and resources, please visit Magellan’s e-Learning Center: http://www.magellanhealth.com/training-site/home.aspx