Transcript Physical health services

State Trends in
Behavioral and Physical
Health Integration
Florida’s Premier Behavioral Health Annual Conference
Catherine Sreckovich
Christina Koster
August 6, 2015
INTRODUCTION
»
Major shifts in recent years in how states approach the delivery and
financing of behavioral health services
› Managed care: Carve in? Carve Out?
› Health Homes
› Navigator programs
»
»
Delivery of behavioral health services is often a function of financing
Stakeholders, however, continue to be concerned about access and
provider and consumer confusion as to how programs are
administered
» New emphasis on value-based purchasing
» Affordable Care Act (ACA) has provided opportunities to states to push
the development of integrated programs for behavioral and physical
health
Page 2
OVERVIEW
»
»
»
»
»
The case for behavioral and physical health integration
Integration continuum
States are taking an active role in moving towards integration
Medicaid behavioral health delivery and payment trends
Lessons learned to date from integration efforts
Page 3
THE CASE FOR BEHAVIORAL AND
PHYSICAL HEALTH INTEGRATION
STATE POLICYMAKERS RECOGNIZE THE CASE FOR
BEHAVIORAL AND PHYSICAL HEALTH INTEGRATION
1
The burden of behavioral health conditions is great
2
3
4
The treatment gap for behavioral health conditions is enormous
5
Delivering behavioral health services in primary care settings reduces stigma and
discrimination
6
7
Behavioral and physical health conditions are interwoven
Primary care settings for behavioral health services enhance access
Treating common behavioral health conditions in primary care settings is cost-effective
The majority of people with behavioral health conditions treated in collaborative primary care
have good outcomes
Page 5
APPROXIMATELY ONE IN FIVE ADULTS HAS A MENTAL
ILLNESS
Percent of Adults (18 or older) with Mental Illness
(2013)
Any Mental Illness
18.5%
Serious Mental Illness (SMI)
4.2%
Serious Thoughts of Suicide in Past Year
3.9%
Substance Use Disorder (SUD)
SUD and SMI
3.2%
1.0%
Source: SAMHSA http://www.samhsa.gov/data/sites/default/files/NSDUH-SR200-RecoveryMonth-2014/NSDUH-SR200-RecoveryMonth-2014.htm and Kaiser Family Foundation
Page 6
MENTAL ILLNESS IS ALSO COMMON AMONG CHILDREN
1 in 5 children in the U.S. have a
diagnosed mental health condition
An estimated one-half of lifetime
mental illnesses begin by age 14
Nearly three-fourths of children with
mental illness are seen in a primary care
setting
Page 7
MENTAL ILLNESS IS MORE THAN TWICE AS PREVALENT
IN MEDICAID BENEFICIARIES AS THE GENERAL PUBLIC
49%
44%
20%
of Medicaid
beneficiaries with a
disability have a
psychiatric condition
of dual eligible
individuals have at
least one mental health
disorder
of dual eligible
individuals have more
than one mental health
disorder
Page 8
PEOPLE WHO NEED BEHAVIORAL HEALTH SERVICES
OFTEN GO WITHOUT TREATMENT
Adults with a diagnosable disorder
who do not receive treatment
60%
Children with a diagnosable disorder
who do not receive treatment
70%
Page 9
BARRIERS KEEP ADULTS AND CHILDREN FROM
ACCESSING BEHAVIORAL HEALTH SERVICES
Reasons for not receiving behavioral health services among
adults reporting an unmet need
Might have a negative effect on job
Might cause others to have a negative opinion
7.90%
9%
Did not feel a need for treatment
9.10%
Concern about confidentiality
9.30%
Treatment would not help
Health insurance did not cover treatment
Did not know where to go for services
Did not have time
Could handle problem without treatment
Could not afford cost
10.60%
11.70%
15.30%
16.30%
26.60%
45.70%
Page 10
BEHAVIORAL HEALTH PREVALENCE IN FLORIDA
Past-Year Major Depressive Episode Among
Adolescents Aged 12-17 in Florida and the
United States
8.8%
8.1%
2009-2010
8.1%
8.1%
2010-2011
Florida
8.0%
9.6%
8.7%
2011-2012
9.9%
2012-2013
United States
Severe Mental Illness (SMI) Among Adults 18 or
Older in Florida and the United States
3.6%
3.9%
2009-2010
3.4%
3.9%
2010-2011
Florida
3.8%
4.0%
2011-2012
United States
4.0%
4.1%
2012-2013
Page 11
INDIVIDUALS WITH BEHAVIORAL HEALTH CONDITIONS COST
$525 BILLION IN HEALTH CARE EXPENDITURES ANNUALLY
»
Medicare and Medicaid have the highest Per Member Per Month
(PMPM) health care costs
PMPM Health Care Costs by Population and Presence
of Behavioral Conditions
$1,450
$1,301
$1,085
$1,057
$582
$381
$340
Commercial
Insurance
Medicare
No MH/SUD
Medicaid
MH/SUD
$397
Total
Page 12
MEDICAID ENROLLEES WITH MH/SUD ACCOUNT FOR 20
PERCENT OF ENROLLMENT BUT 46 PERCENT OF COSTS
Proportion of Medicaid
Enrollees with Mental Health
(MH) and SUD
Proportion of Medicaid Spending on
Enrollees with MH/SUD vs.
No MH/SUD
MH/SUD:
20%
No
MH/SUD:
80%
No MH/SUD:
$166 billion
56%
MH/SUD:
$142 billion
46%
Page 13
MENTAL HEALTH SPENDING BY SETTING (ALL -PAYERS)
Mental Health Spending by Provider Type
Insurance Administration
Retail Prescription Drugs
Specialty Centers
Long Term Care
Office-Based Professionals
Hospitals
Page 14
STATE POLICYMAKERS ALSO RECOGNIZE THAT
INTEGRATION CAN GENERATE COST SAVINGS
Medical costs for treating individuals with comorbid physical and behavioral
health conditions can be 2-3 times as high as those without comorbidities
$
Behavioral
Health
Physical
Health
Physical health services for individuals with behavioral health
co-morbidities cause most of the spending increase
Effective integration can:
» Create opportunity for cost savings
» Decrease total health care costs between 5 and 10 percent
» Provide a real opportunity for cost savings in older patients who suffer
from depression
Page 15
INTEGRATION CAN GENERATE COST SAVINGS
(CONTINUED)
Projected Health Care Cost Savings Through Effective Integration
Payer Type
Annual Cost Impact of Integration
Commercial
$15.8 - $31.6 billion
Medicare
$3.3 - $6.7 billion
Medicaid
$7.1 - $9.9 billion
Total Savings
$26.3 -$48.3 billion
Page 16
BUT, THERE ARE CONSIDERABLE BARRIERS TO
INTEGRATION
Lack of coordination between payers regarding payment
approaches and incentives
Limited access to comprehensive behavioral and physical health
claims data
Concern related to expertise of managed care organizations
(MCO) to manage care for individuals with behavioral health and
substance abuse needs
Limited access to capital for information technology (IT) and
other infrastructure changes
Lack of appropriately trained workforce and wrap-around support
services
Page 17
INTEGRATION CONTINUUM
Low
Behavioral health risk
High
PHYSICAL AND BEHAVIORAL HEALTH NEEDS DRIVE
PATIENT SETTING
Quadrant 2
(high BH risk,
low PH risk)
Quadrant 4
(high BH risk,
high PH risk)
Patients in Quadrant 2 and
Quadrant 4 are served in a
primary care and a specialty
mental health setting
Quadrant 1
(low BH risk,
low PH risk)
Quadrant 3
(low BH risk,
high PH risk)
Patients in Quadrant 1 and
Quadrant 3 are served in a
primary care setting
Low
Physical health risk
High
Page 19
APPROACHES TO BEHAVIORAL AND PHYSICAL HEALTH
INTEGRATION AT THE PROVIDER LEVEL
»
Collaboration between physical and behavioral health providers can
take many forms, ranging in the level of integration
»
»
Varying levels of integration currently occur
Ability of providers to collaborate can be limited by state licensing
and administrative requirements
Minimal
Basic at a
Distance
Basic Onsite
Close Partly
Integrated
Close Fully
Integrated
Integration Continuum
Page 20
STATES AND THE INTEGRATION CONTINUUM
Pennsylvania
Michigan
Washington
Minimal
Basic at a
Distance
Massachusetts
Basic Onsite
Tennessee
Connecticut
Close Partly
Integrated
Close Fully
Integrated
New York
Ohio
Page 21
MINIMAL COLLABORATION:
IMPROVING COLLABORATION BETWEEN PROVIDERS
»
Maintain separate practice, administration and reimbursement
systems – but engage in efforts to collaborate with one and other
»
»
Requires minimal change to the current system
Possible collaboration strategies include:
› Assign patient with complex health needs a case manager
› Consultation over the phone
› Develop practices to share patient information
Minimal
Basic at a
Distance
Basic Onsite
Close Partly
Integrated
Close Fully
Integrated
Page 22
BASIC AT A DISTANCE COLLABORATION:
MEDICAL-PROVIDED BEHAVIORAL HEALTH CARE
»
Patient receives behavioral health services from Primary Care
Provider (PCP)
»
PCP may provide Screening, Brief Intervention, Referral to
Treatment (SBIRT)
› Evidence-based technique, based on an Institute of Medicine report
› Produces referrals to behavioral health
»
PCP receives consultative services from a psychiatrist or Behavioral
Health Provider (BHP)
»
PCP is solely responsible for managing the patient’s care
Minimal
Basic at a
Distance
Basic Onsite
Close Partly
Integrated
Close Fully
Integrated
Page 23
BASIC ON-SITE COLLABORATION:
CO-LOCATION
» BHPs and PCPs provide services to patients at the same location
» Behavioral health and physical health services are provided as two
separate services
»
This can be implemented at the BHP or PCP site
Minimal
Basic at a
Distance
Basic Onsite
Close Partly
Integrated
Close Fully
Integrated
Page 24
CLOSE PARTLY INTEGRATED COLLABORATION:
REVERSE CO-LOCATION
»
Aims to improve care for individuals with SMI
› Co-morbidity is common among this group, when compared to the general
population
› Physical health services are an important part of the care for individuals with
SMI
»
»
PCP stationed part or full-time at the behavioral health site
Health Homes are one delivery system model
Minimal
Basic at a
Distance
Basic Onsite
Close Partly
Integrated
Close Fully
Integrated
Page 25
CLOSE FULLY INTEGRATED COLLABORATION:
UNIFIED PRIMARY AND BEHAVIORAL HEALTH CARE
» Provide behavioral health services as part of primary care
» Consolidate clinical, financing and administrative services within one
organization
»
Combine the patient’s behavioral and physical health history into one
medical record
»
Accountable Care Organizations (ACO) are an example of one
possible delivery system model
Minimal
Basic at a
Distance
Basic Onsite
Close Partly
Integrated
Close Fully
Integrated
Page 26
STATES ARE TAKING AN ACTIVE
ROLE IN MOVING TOWARDS
INTEGRATION
STATES’ ROLE IN BEHAVIORAL HEALTH WILL CONTINUE
TO EXPAND
Medicaid
Expansion
ACA and other
federal regulations
Mental Health Parity and
Addiction Act
Increased insurance
coverage
Provide new opportunities
for coordination
States required to cover mental
health and substance abuse
disorder benefits at the same level
as medical/surgical benefits
Increased used of
behavioral health
services nationwide
Health homes, accountable
care organizations, homeand community-based
waiver programs
Increased Medicaid coverage of
behavioral health conditions
Page 28
STATES ARE INTEGRATING PHYSICAL AND BEHAVIORAL HEALTH
AT THE AGENCY LEVEL TO AID CLINICAL INTEGRATION
Arizona
California
Page 29
ARIZONA ADMINISTRATIVE SIMPLIFICATION
»
Governor Ducey introduced a plan to integrate the Division of
Behavioral Health Services (DBHS), currently part of the Department
of Health Services, into the Arizona Health Care Cost Containment
System (AHCCCS), the Arizona Medicaid Agency
»
»
Simplification effective 7/1/16
»
Does not change the services members receive or how members
receive services
»
»
Simplifies process for providers to care for members
Over 100 DBHS staff will be integrated into AHCCCS divisions for
operational efficiency
Simplifies and consolidates operations of DBHS and AHCCCS
Page 30
ARIZONA ADMINISTRATIVE SIMPLIFICATION
»
Greater Arizona Implementation
› Three Integrated Regional Behavioral Health Authorities (RBHA) as of 10/1/15
› Administers covered behavioral health and physical health services in one plan to
members with SMI
»
Administrative Simplification aligns with Integrated RBHAs
Page 31
ARIZONA ADMINISTRATIVE SIMPLIFICATION
Current
Administrative Simplification
AHCCCS
(Medicaid Agency)
AHCCCS
(Medicaid Agency)
Health Plan
(Physical Health)
ADHS/BDHS
(Behavioral Health)
Health Plan/RBHA
(Physical &
Behavioral Health)
RBHA
Providers
Providers
Providers
Page 32
CALIFORNIA CONSOLIDATION OF MENTAL HEALTH AND
SUBSTANCE ABUSE SERVICES (JULY 2012)
Drug Medi-Cal
Treatment Program
(Department of
Alcohol and Drug
Program)
Medi-Cal Specialty
Mental Health
Services and Early,
Periodic, Screening,
Diagnosis and
Treatment (EPSDT)
(Department of
Mental Health)
Department of Health
Care Services (DHCS)
New Deputy Director of
Mental Health and
Substance Use Disorder
Services, reports directly
to the Director of DHCS
Transition Context:
• State budget deficit
• Broad restructuring of
state government
Page 33
CALIFORNIA’S GOALS FOR CONSOLIDATION
Improve access to culturally appropriate community-based mental
health services
1
4
2
Effectively integrate financing of services
3
Improve state accountability and outcomes
Provide focused, high-level leadership for behavioral health services
within state government
Page 34
STATES ARE FUNDING INTEGRATION EFFORTS THROUGH
A VARIETY OF MECHANISMS
»
Medicaid State Plan Amendments
› Health Homes
»
Medicaid 1115 Demonstrations
› Designated State Health Programs
› Delivery System Reform Incentive Payment (DSRIP) Programs
› SUD Service Delivery
»
Federal Grants
› State Innovation Model (SIM) grants
› Substance Abuse and Mental Health Services Administration grants
› Health Resources and Services Administration grants
»
Joint funding across public and private payers (e.g., Vermont
Blueprint for Health)
Page 35
SUD SERVICE DELIVERY IMPROVEMENT IS A NEW OPTION
THROUGH 1115 DEMONSTRATIONS
»
Section 1115 Demonstrations are available to support states’ efforts
to improve care for individuals with an SUD
Centers for Medicare and Medicaid Services (CMS)identified initiative-specific goals:
Promote strategies to identify individuals with SUD
Enhance clinical practices and promote clinical guidelines
Build aftercare and recovery support services
Coordinate care with primary and long-term care (LTC)
Coordinate with other sources of local, state and federal funds
Encourage increased use of quality and outcome measures
Identify strategies to address prescription and illicit opioid addiction
Page 36
SIM GRANTS HELP STATES FUND INNOVATIVE
STRATEGIES
Outcomes for patients:
• Better healthcare
• Lower costs
• Improved population health
SIM grants provide federal
support to states to
develop and test innovative
healthcare delivery and
payment models
$330
million
$660
million
Awarded to 25
states for Round
One Grants
Awarded to 32
states for Round
Two Grants
Outcomes for systems:
• Improved system performance
• Increased quality of care
• Decreased costs
State options
• Leverage existing delivery system
• Build new capacity
• Opt for pilot programs that integrate care in
limited and incremental ways
Page 37
STATE FUNDED SIM ROUND ONE AND ROUND TWO
TESTING INITIATIVES
SIM Testing Initiatives
Health or Patient Centered Medical Homes
Risk and Shared Savings Payment Model
Team-based integration
Creating one department for mental health oversight
Page 38
OTHER MEDICAID BEHAVIORAL
HEALTH DELIVERY AND PAYMENT
TRENDS
STATE DELIVERY AND FINANCING OF BEHAVIORAL
HEALTH SERVICES CONTINUE TO EVOLVE
Traditionally, behavioral
health services have
been…
• Paid for on a grant or fee-forservice (FFS) basis
• Held separate from the
physical health system (i.e.,
carving out behavioral health
from managed care)
States are now moving
towards…
• Integration of physical and
behavioral health services,
including carve-ins for
managed care and use of
Health Home models, ACOs
• Developing capitated models
specifically for high-need
patients
Page 40
CARVE-OUTS OF BEHAVIORAL HEALTH SERVICES ARE
COMMON IN MEDICAID MANAGED CARE
Benefits Fully Integrated
Benefits Partially Integrated
Page 41
EXAMPLES OF MEDICAID BEHAVIORAL HEALTH CARVE OUTS
Iowa
Washington
Utah
Provides inpatient and outpatient behavioral health and substance
abuse services through one pre-paid health plan
Provides inpatient and outpatient behavioral health services through
county-based Regional Support Networks operating as prepaid health plans
Provides behavioral health services through a prepaid ambulatory health
plan managed by community mental health centers (CMHC)
Pays for behavioral health services separately through FFS; substance
abuse services are provided by MCOs
Page 42
PAYMENT MODELS ALONG INTEGRATION CONTINUUM
Capitated
Managed
Care Model
Oregon
Health Home
Model
Missouri
Traditional
Fee-forService
Primary Care
Case
Management
North Carolina
Vermont
ACO Model
Minnesota
Traditional Fee-for-Service
Low or no care
management or
care
coordination
Potentially
more
unnecessary
service
utilization
Lower potential
cost savings
Full Riskbased
Managed
Care Model
Targeted
Behavioral
Health
Capitated
Managed Care
Model
New York
Full Risk-Based Managed Care
Higher level of
care
management
and care
coordination
Potential for
improved
quality of care
Reduced
inappropriate
utilization and
cost savings
Page 43
PRIMARY CARE CASE MANAGEMENT INTEGRATES
PHYSICAL AND BEHAVIORAL HEALTH SERVICES
States contract directly with providers or procure services through a
primary care case management subcontractor
Vermont
North Carolina
Community Care of North Carolina
(CCNC) Enhanced PMPM Payment
• Enhanced PMPM payments made to each
of the 14 CCNC networks to support
integration
• Funding supported hiring a psychiatrist and
behavioral health coordinator for each
network
• Implementation of behavioral health flags
into an existing electronic care management
tool
Vermont Blueprint for Health
• Integration is part of a statewide multi-payer
initiative to transform primary care practices
into patient-centered medical homes (PCMH)
• Participating PCPs are paid a PMPM fee by
all payers on a sliding scale based on their
NCQA score
• All payers share the costs of Community
Health Teams
Page 44
HEALTH HOMES: A COMMON INTEGRATION STRATEGY
»
Section 2703 of the ACA provides opportunities for Medicaid programs
to develop Health Home services for beneficiaries with chronic
conditions
To be eligible for Health Homes services, beneficiaries must have:
Two or more
chronic
conditions
One chronic
condition and at
risk for a second
Health Homes can be part of a
carve-in or carve-out model
and can target a specific
population
One serious and
persistent mental
health condition
States receive a 90 percent
match for Health Home services
for the first two years
Page 45
HEALTH HOME MODELS INCLUDE ENHANCED, PERSON CENTERED SERVICES
Use of
technology to
support the
services
Referral to
community and
social support
services
Patient and
family support
Comprehensive
care
management
Care
coordination
and health
promotion
Comprehensive
transitional
care
Page 46
OVER ONE-THIRD OF STATES HAVE HEALTH HOME
PROGRAMS
Yes – Health Homes
No – Health Homes
» Health Home programs in 11 states include individuals with SMI
Page 47
PROVIDERS HAVE AN ENHANCED ROLE IN DELIVERING
HEALTH HOME SERVICES
Required to work in teams, so they must become familiar with
capabilities of other service providers and community organizations
Increased role in using data to promote quality improvement
Required to report quality measures to states to receive payment
May be responsible for identifying individuals who are eligible
for Health Home services
Receive a care coordination fee for their role as a Health Home
provider
Page 48
MISSOURI’S APPROACH TO HEALTH HOMES
»
»
st
1
19,000
State to adopt Health
Homes specifically for
SMI populations
Medicaid beneficiaries
enrolled in Health
Homes
$60
Approximate PMPM
payment in cover costs
(in addition to current FFS
or managed care plan
payments)
Statewide program led by CMHCs
PMPM payment includes costs for a Nurse Care Manager, Behavioral
Health Consultant, Health Home Director, Administrative Support
Staff, and Care Coordination staff
Page 49
MISSOURI’S INITIAL HEALTH HOME OUTCOMES
»
Adults continuously enrolled since the inception of the Health Home
program showed marked improvement in key quality metrics related to
management of diabetes, blood pressure, and cholesterol level
Hospital Admissions per 1,000
Emergency Room Use per 1,000
-12.8%*
-8.2%*
*during the program’s
first 18 months
Overall cost reduction:
$2.9 million
Page 50
ACOS: MINNESOTA INTEGRATED HEALTH PARTNERSHIP
(IHP)
»
Delivery systems share in savings during the
first year of participation
»
After the first year, they also share the risk
for losses
»
ACO providers are accountable for:
› Outpatient mental health
› Chemical dependency services
› Medical services
»
Community health workers identify patient
needs such as housing and transportation
and to develop a plan; they also reach out to
patients at homeless shelters, day centers
and correctional facilities
Shared Savings Formula:
Primary
Care
Network
60%
Area
Hospitals
30%
Mental
Health
Centers
Social
Service
Agencies
5%
5%
Page 51
MINNESOTA IHP IS EXPERIENCING SUCCESS
»
$61.5 million in savings in 2014 for 9 provider groups serving
165,000 Minnesotans
»
Based on initial 2014 data, all 9 provider groups were eligible for
shared savings
Emergency department use decreased
9.8%
Primary care visits increased
2.5%
Page 52
STATES ARE MOVING TOWARDS BEHAVIORAL HEALTH
CARVE-INS TO SUPPORT INTEGRATED CARE
Carve Outs
» Require coordination across
multiple managed care or
administrative entities that have
different budgets, information
systems and provider networks
Carve-Ins
» Ability to align incentives at the
MCO level
» Availability of comprehensive
claims data
» Centralized accountability for
cost, quality of care and patient
outcomes
Effective carve-in models require clear and enforceable
contract provisions requiring or incentivizing integrated care
approaches
Page 53
HOW STATES DEAL WITH MCOS SUBCONTRACTING WITH
BHOS
Benefits from carve-in approach can be diluted when an MCO subcontracts with
a BHO in the absence of appropriate contract provisions and oversight
New
Mexico
Keeps financial responsibility with MCOs by including a provision in
its contract that prohibits subcontracts with BHOs on an at risk basis
Includes a minimum medical loss ratio for behavioral health services
on contracts
Allows MCOs to subcontract for behavioral health services, but requires
subcontractors to operate on site in MCO offices to facilitate coordinated care
Page 54
CAPITATED MANAGED CARE: OREGON’S APPROACH TO
INTEGRATION
Coordinated Care
Organizations
(CCOs)
• Manage Medicaid physical and behavioral health benefits
• Part of the State’s effort to consolidate Medicaid and
behavioral health purchasing
• Have benchmark/improvements targets, including those
related to screening of mental, physical and social issues
Primary Care
Behavioral Health
(PCBH) Model
• Available (but not required) for CCOs and clinics
participating in Oregon’s Patient-Centered Primary Care
Home (PCPCH) model
• Primary care teams include a behavioral health provider
• Primary care clinics screen patients for mental, physical
and social health concerns
Page 55
CAPITATED MANAGED CARE: OREGON’S APPROACH TO
INTEGRATION, CONTINUED
Alternative Payment
Methodology (APM)
Pilot Program
Other Integration
Support
• PMPM fee to Community Health Centers (CHC) to
encourage the transition to VBP
• Experiments with embedding behavioral health
professionals on physician teams
• State is collecting data to analyze how payments could
facilitate VBP and support CHC financial stability
• Use of broad stakeholder group to address barriers
(Integrated Behavioral Health Alliance of Oregon)
• Expansion of All Payer Claims database to include all
behavioral health claims (potential need for legislation)
• Development of solutions to address barriers to
behavioral health information sharing
• Development of statewide workforce standards for
community health workers, personal navigators and peer
wellness specialists
Page 56
CAPITATED MANAGED CARE: WASHINGTON’S PROPOSED
APPROACH
»
2014 law changes how the State purchases
Medicaid mental health and chemical
dependency services:
› Current physical health managed care plans are
eligible for a new integrated managed care model
to provide:
• Non-Medicaid mental health and SUD
treatment benefits to Medicaid enrollees
• Medicaid medical, mental health and SUD
treatment
› Both contracts will be released under same
procurement and awarded to the same bidders
› A third, separate contract, will be for crisis services
and non-Medicaid services for non-Medicaid
individuals, to be managed regionally by a single
entity
Page 57
TARGETED CAPITATED MODELS CAN IMPACT HIGH -NEED
PATIENTS
Target a specific population
(i.e., consumers with a SMI or SUD)
Give responsibility for the
full range of physical,
behavioral and social needs
to one MCO
Targeted
Capitated
Model
Include enhanced health
plan standards
Some concern exists
regarding the potentially
stigmatizing effect of a
separate delivery system
Page 58
TARGETED CAPITATED MODEL:
NEW YORK’S HEALTH AND RECOVERY PLANS (HARPS)
Ongoing implementation; first phase of enrollment begins
in New York City in Fall 2015
Integrated managed care product for individuals with SMI
or SUD, plus high-risk utilization patterns or functional
deficits
Subject to more extensive behavioral health staffing and
experience requirements than those for MCOs enrolling
individuals with less serious behavioral health needs
Required to include recovery-oriented home-and
community-based services, such as employment and
education supports
Page 59
NAVIGATORS CAN COMPLEMENT A VARIETY OF
INTEGRATION MODELS
Navigators are informed
companions that:
Support an individual in
navigating the health care
system
Promote patient
engagement to help
achieve better-integrated,
more holistic care
Navigators can include:
• Nurses
• Licensed clinical social
workers
• Paraprofessionals
Example: Pennsylvania’s Wellness Recovery Teams
• Piloted in Montgomery County
• Identify and engage adults with SMI who also have at least one chronic medical
condition
• Include Medicaid-funded navigators, a registered nurse with behavioral health
experience, and a Master’s level behavioral health professional
• Form relationships with professionals from all the agencies support the
consumer’s care
• Emergency room visits for medical care declined by 11 percent in the first six
months
• Psychiatric and medical inpatient admissions fell by 43 and 56 percent,
respectively
Page 60
STATES ARE INTRODUCING BUNDLED PAYMENTS FOR
BEHAVIORAL HEALTH EPISODES
Arkansas
» Attention Deficit Hyperactivity Disorder (ADHD)
› Diagnosis of ADHD triggers the episode
› The Principle Accountable Provider is the provider (primary
care or mental health provider) with the majority of visits
› Time period is 12 months
› Costs include all ADHD related charges
› Medicaid is the only participating payer
» Oppositional Defiant Disorder episode under development
Tennessee
» Developing episodes for behavioral health conditions including:
› ADHD
› Anxiety
› Post Traumatic Stress Disorder
› Schizophrenia
› Depression
» Implementation timeframe ranges from 2015 - 2019
Page 61
FLORIDA’S INTEGRATION OF PHYSICAL AND BEHAVIORAL
HEALTH
»
Provides physical and behavioral health services for Medicaid
beneficiaries through the Managed Medical Assistance (MMA) Program
»
First state to offer individuals with
SMI an exclusively designed
Medicaid managed care health plan
› Offered as an MMA specialty plan
› Enrollment began July 2014
› Each enrollee must have a care plan and
peer support group
› Specialty plans have enhanced network
adequacy requirements
Page 62
LESSONS LEARNED TO DATE FROM
INTEGRATION EFFORTS
PAYERS NEED TO KEEP UP WITH INTEGRATION
Address same day
billing issue
Caring for patients with
comorbid conditions may
involve a behavioral health
and a physical health visit
on the same day
Same day visits are not
always reimbursed under
Medicaid
Develop billing
codes for emerging
treatments
Redefine provider
types
As of 2012, only 16 states
had a billing code for the use
of SBIRT
Limits on types of
practitioners who may bill
for behavioral health
services
Limits on procedures or
diagnosis codes for which
primary care practices may
receive reimbursement for
behavioral health services
Page 64
DATA EXCHANGE PRESENTS CHALLENGES TO
PROVIDERS – WHAT STATES NEED TO DO
Provider Challenges
State Agency Solutions
Confusion about
regulations
Provide guidance on State
regulations
Obtaining patient consent
Standardize consent forms
Reliance on other providers
Implement provider
immunity laws
Cost of technology
adoption
Offer funding for technical
assistance
Page 65
Source: Robert Wood Johnson Foundation
STATE EFFORTS TO MINIMIZE DATA SHARING
CHALLENGES
State
Legislative Action
North Carolina Health Information Exchange Act (NCHIE)
• Creates a voluntary, statewide electronic health information exchange (NC Network)
• Supersedes state privacy laws regarding information sharing
• Authorizes data exchange in accordance with HIPAA
Nevada
Nevada Public Health and Safety Code
• Exempts entities from complying with any state health information privacy law that is more
onerous than HIPAA regulation
Statewide Health Information of New York (SHIN-NY)
• Connects physical and behavioral health providers through the development of a statewide
electronic network (SHIN- NY)
• Enables providers to connect in real time and share patient health information
• Utilizes a standard consent form that covers any information exchanged by providers (both
physical and behavioral health)
Illinois
Health Information Exchange and Technology Act
• Grants immunity to health care providers, who in good faith, treat a patient using
information accessed through the statewide health information network
Page 66
POTENTIAL REDUCTIONS IN PROVIDER AND STATE
FUNDING EXIST WHEN MOVING TO MANAGED CARE
Reduced use of
CMHCs
Decreased
CMHC financial
stability
Decreased
Federal
Medicaid match
for states
Page 67
EXAMPLES OF SHIFTS IN USE OF CMHCS UNDER
MANAGED CARE
Tennessee
Kentucky CMHCs ended 33 of the
approximately 50 daytime therapeutic
programs
In Tennessee, several CMHCs closed due to:
› Decreases in state funding
› Lower reimbursement to safety net providers and
CMHCs from MCOs
› Steerage of Medicaid consumers with severe and
persistent mental illness to non-CMHCs by MCOs
Kentucky
Some states, including Florida, require contracting with CMHCs under managed care contracts
Page 68
WORKFORCE ADEQUACY CONCERNS
Projected 194,000 Job Openings
Between 2010 - 2020
2,600+
Number of Mental Health
Professional Shortage
Areas in the United
States
102,000 due to
replacement
demand
92,000 due to
growth
Page 69
WORKFORCE ADEQUACY CONCERNS
Concerns over the adequacy of the behavioral health workforce are likely to
intensify as individuals gain insurance through the ACA
Workforce Adequacy Challenges
State Agency Solutions
Shortage of behavioral health
and primary care providers
Introduce new entry and mid-level
occupations
Isolated training is not adequate
for interdisciplinary care
approach
Use evidence-based practices in initial
clinical training
Disproportionate geographic
distribution (especially in rural
areas)
Address retention issues at the state and
local level, use telehealth
Page 70
BEHAVIORAL HEALTH PROVIDER NETWORK
CHALLENGES: NEW MEXICO’S EXPERIENCE
» Included behavioral health in move to nearly universal managed care (2014)
» Long-standing behavioral health provider capacity issues in state
» Significant upheaval in behavioral health provider network
A 2013 fraud and
abuse investigation
resulted in closures of
12 of the state’s
largest behavioral
health providers
Two major providers
who assumed services
for those 12 providers
exited the state in
2015
Most of the services
are now being
transitioned to
Federally Qualified
Health Centers
(FQHC)
Page 71
CONCLUSION
THE EVOLUTION CONTINUES…
States continue to
reform their
programs, even
when full
capitation is in
place
Administrative
support and
regulations needs
to keep up with
program changes
Other payers are
actively involved in
state reform efforts
(e.g., Arkansas,
Tennessee,
Vermont)
Will continue to
evolve rapidly with
introduction of
state and federal
laws and
regulations
• Include additional services
and populations in the
capitated program
• Focus capitated programs
on specific needs
populations
• Introduce Health Home and
ACO components
Page 73
IF FINALIZED, CMS PROPOSED MEDICAID MANAGED CARE
REGULATIONS WILL FURTHER IMPACT DELIVERY OF BEHAVIORAL
HEALTH SERVICES
»
Require time and distance network adequacy standards for adult and
pediatric behavioral health providers
»
Allow states to reimburse behavioral health providers, among others,
for the adoption and use of interoperable health information
technology through Medicaid
»
Codifies principles for managed long-term services and supports
programs
»
Permit states to include short-term stays in institutions for mental
diseases for adults (ages 21-64) in their managed care capitation
payments; intended to alleviate shortages in short-term inpatient
mental health and SUD treatment, through better financing options
Page 74
DISCUSSION
REFERENCES
»
A Critical Need for Mental (and Behavioral) Health Workforce Training. American Psychological Association. March 2009.
Available online: http://www.apa.org/health-reform/pdf/mental-health-workforce.pdf
»
A Snapshot of the Florida Medicaid Managed Medical Assistance Program. Florida Agency for Health Care
Administration. May 2015. Available online:
http://www.fdhc.state.fl.us/Medicaid/statewide_mc/pdf/mma/SMMC_MMA_Snapshot.pdf
»
Alba Solular, D. La Frontera CEO confirms group might leave New Mexico. Las Cruces Sun-News. February 2015.
Available online: http://www.lcsun-news.com/las_cruces-news/ci_27610208/la-frontera-reportedly-plans-leave-newmexico
»
Bachrach, D., Anthony, S. and Detty, A. State Strategies for Integrating Physical and Behavioral Health Services in a
Changing Medicaid Environment. Commonwealth Fund. August 2014. Available online:
http://www.commonwealthfund.org/~/media/files/publications/fundreport/2014/aug/1767_bachrach_state_strategies_integrating_phys_behavioral_hlt_827.pdf
»
Behavioral Health Barometer: Florida, 2014. Substance Abuse and Mental Health Services Administration. 2014.
Available online: http://www.samhsa.gov/data/sites/default/files/State_BHBarometers_2014_1/BHBarometer-FL.pdf
»
Belfort, R., et al. Integrating Physical and Behavioral Health: Strategies for Overcoming Legal Barriers to Health
Information Exchange. Robert Wood Johnson Foundation. January 2014. Available online:
https://www.manatt.com/uploadedFiles/Content/4_News_and_Events/Newsletters/IntegratingPhysicalandBehavioralHealt
h.pdf
»
Brown, D. and McGinnis, T. Considerations for Integrating Behavioral Health Services within Medicaid Accountable Care
Organizations. Center for Health Care Strategies, Inc. July 2014. Available online: http://www.chcs.org/media/ACO-LCBH-Integration-Paper-0709141.pdf
REFERENCES
»
CMS State-specific managed care summaries, based on August 2014 information. Available online at:
http://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/medicaid-managed-care/stateprogram-descriptions.html
»
CMS Technical Assistance Brief: State Options for Integrating Physical and Behavioral Health Care. Centers for
Medicare and Medicaid Services. October 2011. Available online:
http://www.healthtransformation.ohio.gov/LinkClick.aspx?fileticket=0zJCWaw_O3Q%3D&tabid=122
»
Collin, et al, Evolving Models of Behavioral Health Integration in Primary Care. Milbank Memorial Fund. May 2010.
Available online: http://www.milbank.org/uploads/documents/10430EvolvingCare/10430EvolvingCare.html
»
Core Set of Health Care Quality Measures for Medicaid Health Home Programs: Technical Specifications and Resource
Manual for Federal Fiscal Year 2013 Reporting. Center for Medicaid and CHIP Services. March 2014. Available online:
http://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/health-homes-technicalassistance/downloads/health-home-core-set-manual.pdf
»
Department of Health Care Services. Transition Plan: Transfer of Medi-Cal Related Specialty Mental Health Services
from the Department of Mental Health to the Department of Health Care Services, effective July 1, 2012. October 1,
2011. Available online: http://www.dhcs.ca.gov/services/medi-cal/Documents/MediCal%20Mental%20Health/Mental%20Health%20Services%20Transition%20Plan%20-%20October%201%202011.pdf
»
Dilonardo, Joan. Workforce Issues Related to: Physical and Behavioral Healthcare Integration, Specifically Substance
Use Disorders and Primary Care. Substance Abuse and Mental Health Services Administration. August 2011. Available
online: http://www.integration.samhsa.gov/workforce/Workforce_Issues_Related_to_Physcial_and_BH_Integration.pdf
Page 77
REFERENCES
»
Galewitz, Phil. Florida Shifts Medicaid Mental Health Strategy. Kaiser Health News. July 2014. Available online:
http://khn.org/news/florida-program-for-mental-health-coverage/
»
Garfield, Rachel L. for Kaiser Commission on Medicaid and the Uninsured. Mental Health Financing in the United States:
A Primer. April 2011. Available online: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8182.pdf
»
Grantham, D. New Mexico AG clears first of 12 behavioral health providers in Medicaid fraud probe. Behavioral
Healthcare. January 2014. Available online: http://www.behavioral.net/article/new-mexico-ag-clears-first-12-behavioralhealth-providers-medicaid-fraud-probe
»
Grantham, D. Fraud? 15 Providers defunded by state; none face charges. Behavioral Healthcare. July 2013. Available
online: http://www.behavioral.net/article/fraud-15-providers-defunded-state-none-face-charges
»
Hamblin, Allison from CHCS and Verdier, James and Au, Melanie from Mathematica Policy Research. Integrated Care
Resource Center Technical Assistance Brief. State Options for Integrating Physical and Behavioral Health Care.
October 2011. Available online: http://www.integration.samhsa.gov/integrated-caremodels/Integrated_Care_Briefing_Paper_models_of_integration_analysis_10-6-11.pdf
»
Hostetler, C. et al. Origins in Oregon: The Alternative Payment Methodology Project. Health Affairs. April 2014. Available
online: http://healthaffairs.org/blog/2014/04/14/origins-in-oregon-the-alternative-payment-methodology-project/
»
Integrating Physical and Behavioral Health Care for Medicaid Through Managed Care. Amerigroup Policy Brief. 2013.
Available online: http://hcr.amerigroupcorp.com/wpcontent/uploads/2013/06/Integrating_Physical_and_Behavioral_Health_Care_for_Medicaid_Through_Managed_Care.pdf
»
Integrating Behavioral Health within Medicaid Accountable Organizations: Emerging Strategies. Center for Health Care
Strategies Webinar. February 2015.
Page 78
REFERENCES
»
Issue Brief: Integrating Physical and Behavioral Health Care: Promising Medicaid Models. Kaiser Family Foundation.
February 2014. Available online: http://www.integration.samhsa.gov/integrated-caremodels/Kaiser_brief_on_integrated_health_2014.pdf
»
Kronick R et al, The Faces of Medicaid III: Refining the Portrait of People with Multiple Chronic Conditions, Center for
Health Care Strategies, October 2009.
»
Lindebald, M. Draft Non-Medicaid Contract for Apple Health – Fully Integrated Managed Care. Washington State Health
Care Authority. June 2015. Available online: http://www.hca.wa.gov/hw/Documents/FIMC_Non-Medicaid_Contract.pdf
»
Lindstrom, W. CEO Report. New Mexico Behavioral Health Collaborative Meeting. July 2015. Available online:
http://www.bhc.state.nm.us/
»
Malone, P. La Frontera CEO: New Mexico expansion a ‘nightmare.’ Santé Fe New Mexican. February 2015. Available
online: http://www.santafenewmexican.com/special_reports/mental_health_shake-up/la-frontera-ceo-new-mexicoexpansion-a-nightmare/article_e154ae48-7c36-51d2-86c7-16374c43ff28.html
»
Meleck, S., et al. Economic Impact of Integrated Medical-Behavioral Healthcare. Prepared by Milliman for the American
Psychiatric Association. April 2014.
»
Missouri Department of Social Services: Health Homes Implementation Process, Frequently Asked Questions. March
2014. Available online: http://dss.mo.gov/mhd/faq/pages/health-homes-implementation-staff.htm
»
National Expenditures for Mental Health Services and Substance Abuse Treatment. Substance Abuse and Mental Health
Services Administration. Department of Health and Human Services. 2013. Available online:
http://www.samhsa.gov/data/node/20
Page 79
REFERENCES
»
New Service Delivery Opportunities for Individuals with a Substance Use Disorder. Federal Policy Guidance: Centers for
Medicare and Medicaid Services. Department of Health and Human Services. July 2015. Available online:
http://www.medicaid.gov/federal-policy-guidance/downloads/SMD15003.pdf
»
Pourat, N., et al. One-Stop Shopping: Efforts to Integrate Physical and Behavioral Health Care in Five California
Community Health Centers. UCLA Center for Health Policy Research. January 2015. Available online:
http://healthpolicy.ucla.edu/publications/Documents/PDF/2015/integrationbrief-jan2015.pdf
»
Primary Care Collaborative. Integrated Health Partnerships Initiative. July 2015. Available online:
https://www.pcpcc.org/initiative/integrated-health-partnerships-initiative
»
Reynolds, C. and Scalia, K. Catalyst for Improved Care: Integrating Behavioral Healthcare Providers into ACOs.
Netsmart. January 2015. Available online: http://files.himss.org/FileDownloads/2015-0624%20NetSmart%20ACO_Catalyst_1915.pdf
»
State Innovation Models (SIM) Initiative Evaluation: Model Design and Model Pre-Test Evaluation Report. Centers for
Medicare & Medicaid Services. July 2014. Available online: http://downloads.cms.gov/files/cmmi/SIM-Round1ModelDesign-PreTest-EvaluationRpt_5_6_15.pdf
»
Strategies to Support the Integration of Mental Health Into Pediatric Primary Care. National Institute for Health Care
Management. August 2009. Available online: http://www.nihcm.org/pdf/PediatricMH-FINAL.pdf
»
Substance Use and Mental Health Estimates from the 2013 National Survey on Drug Use and Health: Overview of
Findings. Substance Abuse and Mental Health Services Administration. September 2014. Available online:
http://www.samhsa.gov/data/sites/default/files/NSDUH-SR200-RecoveryMonth-2014/NSDUH-SR200-RecoveryMonth2014.htm
Page 80
REFERENCES
»
The Adequacy of the Behavioral Health Workforce to Meet the Need for Services Overview of Key Findings. Advocated
for Human Potential, Inc. July 2014. Available online: http://www.ahpnet.com/Files/AHP-BH-Workforce-Paper-July2014.aspx
Page 81