Transcript Document

Integrated Behavioral
Health Care
- Funding
Module 6
W. Patrick Sullivan, PhD
Indiana University
Learning Objectives
1. To describe key provisions in the PPACA and how
they impact the effort to integrate care
2. Discuss how the PPACA hopes to expand health
insurance and ensure access to care for all citizens
3. Discuss fiscal barriers to integrated care as well as
fiscal mechanisms that encourage integration
4. Explore different reimbursement models that
undergird health care and the implications for how
services are delivered
5. Explore how these initiatives impact social work
practice
Disproportionate Cost Burden
•
•
•
Over half of all Medicaid beneficiaries with disabilities are
diagnosed with mental illness
For those with chronic conditions health care costs are as
much as 75% higher for those with a mental illness – with
the rates for those with a co-occurring substance use
disorder resulting in a two to three fold cost increase
Among those eligible for both Medicaid and Medicare 44%
have 1 mental health diagnosis 20% have more than 1
mental health diagnosis1 (Integrated Care Resource
Center, 2011, p. 1).
Barriers to Reimbursement for Integrated Care2
1.
2.
3.
4.
5.
6.
7.
State Medicaid limitations on payments for same-day billing for physical health and
a mental health service visit/service
Lack of reimbursement for collaborative care and case management related to
mental health services
Absence of reimbursement for services provided by non-physicians, alternative
practitioners, and contract practitioners
Medicaid disallowance of reimbursement when primary care practitioners submit
bills listing only a mental health diagnosis and corresponding treatment
Level of reimbursement rates in rural and urban areas (case mix issues,
telemedicine, care coordination)
Difficulties in getting reimbursements for mental health services in school-based
health center settings
Lack of reimbursement incentives for screening and providing preventative mental
health services in primary setting
PPACA: Expanding Coverage3
By 2014 all individuals under the age of 65 who have incomes
below 133% federal poverty level will be eligible – of the
projected newly eligible 17.5% are estimated to have a mental
illness or substance use disorder
Those who do not qualify for Medicaid will have access to
insurance through the State Exchanges
PPACA: Health Insurance Exchanges
• Provides an opportunity for low to middle income persons
and small businesses to purchase health insurance
• Available to those up to 400% of Federal Poverty Level
• Exchanges are designed to help consumers determine their
eligibility for the exchange – screening process also informs
those who are eligible for Medicaid, CHIP or other plans
• Plans must offer the Essential Health Benefits
• If States fail to establish exchanges on Jan 1 2014 the
federal government will operate the exchange
PPACA: Parity
•
•
•
Parity in the essential benefit package
Prohibitions from capping annual and lifetime benefits
for mental use and substance use disorders treatment
at levels below physical health care
Behavioral health benefits are essential services in
state exchanges – mental disorders and substance
use disorder services and are considered essential
services in Medicaid “benchmark” expansions
Health Insurance Exchange Plans
Plans must offer the Essential Health Benefits
• There are four levels with plans paying covered costs at Bronze
(60%), Silver (70%), Gold (80%) and Platinum (90%)
• The “premium assistance credit” is a refundable tax credit for
those who purchase through the exchange - This is based on
income -- IRS pays the pays the premium assistance credit
amount directly to the insurance plan.
• The benefit package and overall plans available will determine the
degree to which this aspect of the ACA will forward the goals of
Integrated care
PPACA: Medicaid Expansion4
• If states opt into expansion – from 2014 to 2016 Federal
government will finance 100% of those who become eligible due
to expansion and by 2020 this drops to 90%
• At present 49 of 66 million Medicaid beneficiaries are enrolled in
some form of managed care
• Estimates suggest that if health care reform is fully executed
including expansion– by 2019 an additional 3.7 million people
facing severe mental illness will gain coverage
• Among those without serious disorders 27.6 will gain coverage
Medicaid Participation5
• In a recent survey – Medicaid participation rates (the
percentage of those who are eligible who enroll) was
estimated at 62.6%
• State variation ranging from 43% (Arkansas) to 82.8%
(Massachusetts)
• Participation higher among disabled adults (75.8%)
and lowest among “childless” adults 38.3% - and
“category of eligibility” is seen as the strongest
predictor of take up rates
Participation Factors
•
More generous benefits in state plans – including
preventive dental care and other optional services
•
Increasing provider reimbursement
•
Increases in recipient cost sharing results in lower
rates
•
As an interaction effect the above may increase the
odds that an individual may interact with providers
who will facilitate, rather than discourage, enrollment
PPACA: Mechanisms to Integrate Care
1. Medical Homes - builds on primary care, the chronic care model,
patient-centered care and health information technology
• For those with serious behavioral health challenges – a Behavioral Health
Organization can become the primary medical home
2. Accountable Care Organizations: In general for those enrolled in
Medicare
•
•
Groups of providers who form collaborative agreements to share
responsibility, improve quality and control costs
There is great potential for behavioral health to be key players in ACO’s
depending on contractual details, risk-sharing obligations and
opportunities, and reimbursement mechanisms.
PPACA: Medicare6
•
•
•
•
•
Goal to slow growth in Medicare costs through improvements in care
An ACO “assumes responsibility for a clearly defined population of
Medicare beneficiaries, attributed to it on the basis of their patterns of
primary care”
One key feature if ACO’s is shared savings – requiring the provision
of high quality care and “reducing cost below what would have been
expected”
But similar to provisions in Medicare – recipients have the opportunity
to opt out.
The opportunity for shared savings will be a factor in an ACO’s
willingness to assume risk
ACO Structure
•
•
•
•
•
ACO’s must include primary care providers who cover at
least 5000 Medicare beneficiaries
Have a formal legal structure
Possess a leadership and management structure that
includes clinical and administrative systems
Provide data on cost and quality and other items requested
by CMS
Accept principles of evidence-based medicine, “patient”
engagement, and “patient centeredness”
Shared Savings
1.
2.
3.
4.
Stakeholders including providers and payers must work together
to identify targets that reduce cost and reduce variations in order
to ensure quality care
Evaluate objectively and together if targets were met and
measure savings
All should share success (financial) that provides equitable
rewards to stakeholders and avoids “perverse incentives” (i.e.
rewarding volume over quality for example)
Engage in the process of continued monitoring to ensure quality
of care is improved
Questions to Ponder
How can the cost of providing care be reduced while still
meeting quality standards?
What role might social workers play in the effort to reduce
costs while enhancing quality?
What traditional social work roles fit well within an ACO
framework?
Could social work play a prominent role in an ACO
framework? Why?
Mechanisms to reduce cost and accrue
savings
1. Successful prevention activities – including promoting healthy
lifestyle choices, preventative care, screening and early detection
2. Reduction in the overall “quantity” of services used
3. Substitution of less intensive and less expensive services for
intense expensive care – i.e. reduction in use of the emergency
room for non-emergencies and inpatient hospitalization
4. Less reliance on specialty ancillary services and greater
emphasis on natural community supports
5. Effective use of group modalities – including peer supports
6. Use of alternative delivery methods include telemedicine
Social Work in a “shared savings”
environment
• Case and care management, traditional social work
roles may be emphasized in accountable care and
other “at risk” delivery models
• Social work has great experience in working with those
facing the greatest challenges including those with
significant physical, mental, and developmental
challenges that can be costly to serve in medical
settings
• Social work emphasis on tapping community resources
and natural supports can lead to effective and less
costly care
PPACA: Increased Funding for Integrated
Care
Increased reimbursement for primary care:
Regardless of a fee-for-service arrangement or within a
managed care plan – reimbursement for primary care
is slated to increase by half
Co-location of services:
Additional grants are available for co-location of
primary and specialty care in behavioral health settings
PPACA: Services for Co-Occurring Disorders
Home and community-based services for those with cooccurring disorders.
• Services can include: vocational support, case
management, peer support
• These services can be offered as a part of a regular state
Medicaid program (to people with incomes up to 300% of
maximum SSI payment and high need
• Or through a waiver granted by HHS
PPACA: Infrastructure Supports
•
•
•
Community-based Collaborative Care Network Program: The
development of a collaborative consortium of providers to coordinate
and integrate services
Federal Coordinated Care Office: Designed to help those who are
dually eligible for Medicaid and Medicare and will attempt to reduce
fragmentation and the navigation challenges people face trying to work
in both systems.
Workforce Development: The ACA sets aside funds to support training
programs on medical homes, team management of chronic illness, and
integration of physical health and behavioral health care
Options for Integrating Care
• Leverage existing delivery system or build new
capacity
• Have Managed Care Organizations or Behavioral
Health Organizations take the lead in integration efforts
• Develop a single integrated system or multiple,
specialized systems of care for subsets of beneficiaries
Components of Integrated Care
• Aligned financial incentives across physical and behavioral health
systems
• Real-time information sharing across systems to ensure that
relevant information is available to all members of a care team
• Interprofessional care teams that are accountable for coordinating
the full range of medical, behavioral, and long term support
services as needed
• Competent provider networks
• Mechanisms for assessing and rewarding high quality care
Managed Care Organizations7
In places where the normal plan has been to carve out
behavioral health care, states must contract with entity
prepared to offer integrated care – or the MCO can
subcontract for behavioral health services
However: agreements must be secured for onsite
services - and same day billing for physical and
behavioral health care must be allowed.
MCO: Pros & Cons
Pros:
•
Administrative systems are integrated and data needed for care
management is accessible
•
Seamless system for beneficiaries
•
Clinical integration is possible
Cons:
•
Subcontracts may thwart true integration
•
Clinical capacity to recognize and provide effective services for
behavioral health issue may be lacking
•
Special MCO’s for those with serious and persistent mental illnesses
may be needed
Primary Care Case Management
•
Does not require the use of a MCO –
the integration initiative can be
achieved via:
•
•
•
•
Offering enhanced fees to primary
care entities to support care/case
management
Support development of community –
based care teams to “extend the
reach of primary care.”8
Support health information technology
for information exchange, population
management, performance
measurement
Develop other incentives to integrate
care
• Pros: Can build on
existing systems –
including fee-for-service
models
• Cons: Infrastructure may
be difficult to build –
implementation may be
difficult
Behavioral Health Organization
•
Here the organizations
have expertise with those
with significant behavioral
health challenges - this
moves toward the idea of
a Patient-Centered
Medical Home where a
BHO is the designated
home
• Pros – all those we
observed with standard
MCO’s with the exception
that these organizations
have a greater capacity to
serve this special
population
• Cons – little experience
using this arrangement to
date
MCO/PCCM/BHO Partnership
• Partnership facilitated by financial alignment
•
•
•
•
•
Develop shared saving models
In capitated environment this can be accomplished in a
prospective payment plan
Fee for service requires that shared savings are calculated
Performance incentives
This can maintain current BHO carve-outs which may remain
the most viable plan for the serving those facing serious
mental illnesses
Pros & Cons
• Pros:
Risk can be shared widely
Shared administrative costs and functions
Can facilitate shared record keeping and the
development of a client registry
• Cons:
Separate systems remain
Shared saving difficult to calculate
Controlling costs may trump providing appropriate care
Reimbursement Issues
•
•
•
•
•
Same day visit billing barriers
• Under Medicaid law, states may charge for same-day medical and
mental health visits, with matching dollars provided, however, states
do not take advantage of this opportunity
Historically many states have implemented primary care case
management programs that limit a beneficiaries free choice of provider
There is considerable confusion about billing for ICM services with no
clear guidelines
States will decide the qualified providers eligible to receive ICM payments
States will decide if reimbursement is for a set of activities (what a
provider “does”), practice characteristics (what a provider “is”) or
improvements in practice behavior (how the provider performs)
Aligning Fiscal Incentives
•
•
•
•
•
Create incentive payments for providers who demonstrate improved
performance on quality and cost measures
Reimbursing providers on a per-member-per-month based on care
coordination
Quality incentive programs calculated as a percentage of program savings
which can be shared directly with providers or provider networks as “shared
savings”
States plans may need to seek approval or a “waiver” to test some of these
new initiatives – particularly when choice is restricted and benefit plans are
altered
States can also set payments on a stratified basis distinguishing low to high
case management needs
Billing for Integrated Care
• Proper use of Health and Behavioral Assessment Billing Codes
and modification of same can be used to properly to advance
integrated care
• Ensure codes include assessment activities, education, and
cognitive and behavioral, and services geared toward health and
illness management, i.e.,diet, exercise, smoking cessation
• Include codes for group interventions – and even educational and
instruction (relaxation training, medication management) to family
with and without identified client present
Reimbursement Continuum
Fee for Service
Full Risk Capitation
There a wide range if reimbursement models in health
care. These models determine what services are
reimbursable and those that are not, have implications
for professional autonomy, and in many ways support
or hinder the integration of care.
In a simplified world – the continuum ranges from the
traditional fee-for-service model on one end – and full
risk capitation on the other.
In Fee for Service
• Each discrete reimbursable service is billed
separately
• There can be a built in incentive to provide more
services – and the most expensive services
• In contrast, services that the consumer need may be
more costly that the rate of reimbursement – creating a
disincentive for use
Fee for Service cont….
• When specialty providers are used, the mechanism to
integrate care from basic communication to shared
information may be lacking due to a lack of a system or
a designated gatekeeper
• This model offers maximum autonomy to professionals
within the fiscal parameters of the primary source of
funding
At the other end of the continuum….
Full Risk Capitation
• Providers are paid a set rate per person prospectively
(often per person per month) to provide the necessary
services for a member
• When the provider spends less than the prospective
payment rate they profit – if they exceed the cap they
lose (hence the term “at risk”)
Full Risk Capitation cont…..
• By remaining unfettered from a fee-for service
framework that determines what services are
reimbursable this model allows for flexibility in the
range of services offered
• Because fiscal risk is involved, care and case
management become key services, preventative
services are emphasized, and disease management
and chronic care approaches can be useful
Full Risk Capitation cont…
• Because providers are at risk there may be an
incentive to avoid high risk and expensive clients
• There is an incentive to reduce the use of intensive
and expensive services (i.e. hospitalization) even if
such services are truly necessary
• Because of the business model issues like prior
authorization and concurrent review puts clinical
decisions in the hands of non-clinicians – thus reducing
professional autonomy
Key Questions
When considering the various models offered above and
they key premises of each – what are some pros and
cons of these service delivery mechanisms for the
individual client, professional, and society?
What ethical dilemmas may be posed in the effort to
reduced costs while enhancing quality – and how does
one balance the two concerns?
Should efforts be made to extend care to every citizen?
Is Reform Going to Happen?
• Given the timeline, challenges, and political environment the
final product can take many forms
• Given that Medicaid is a federal-state program how states
will respond to various expansion initiatives remains to be
seen – based on Supreme Court Decision on Individual
Mandate, States can opt of the expansion
• Optional programs may be difficult to launch in current
economic environment – and those most important to
service integration may be in the greatest peril
Key Challenges
•
•
•
•
Demand for behavioral health care services will increase
The number of available professionals may be inadequate
Benchmark coverage under expansion only requires that
coverage is comparable to private insurance therefore,
some optional services that may be central to the care of
people with chronic conditions may not be covered
Exchange programs may not work to enroll people with
chronic conditions
References
1.
2.
3.
4.
5.
6.
7.
8.
Integrated Care Resource Center (2011, October). State Options for Integrating Physical and Behavioral
Health Care, p. 1-12.
Mauch, D., Kautz, C., & Smith, S. (2008, Feb). Reimbursement of mental health services in primary care
setting. Rockville, MD:SAMHSA
Croft, B., & Parish, S. (2012, Feb.) Care integration in the Patient Protection and Affordable Care Act:
Implications for Behavioral Health. Administration and Policy in Mental Health and Mental Health Services
Research.
Iglehart, J. (2011). Desperately seeking savings: States shift more Medicaid enrollees to managed care.
Health Affarirs, 30(9), 1627-1629
Sommers, B., Tomasi, M., Swartz, K., & Epstein, A., (2012). Reasons for the wide variation in Medicaid
participation rates among states hold lessons for coverage expansion in 2014. Health Affairs, 31(5), 909919.
Berwick, D. (2011). Launching accountable care organizations – the proposed rule for Medicare shared
saving program. The New England Journal of Medicine, 364(e32), 1-4.
Hamblin, A., Verdier, J., & Au, M. (2011, October). State options for Integrating Physical and Behavioral
Health Care. Integrated Care Resource Center. Technical Assistance Brief, 1-12.
Hamblin, A, Somers, S., Neese-Todd, S., and Mahadevan, R. (2011, January). Medicaid and Criminal
Justice: The Need for Cross-System Collaboration Post Health Care Reform. Exploring Health Reform and
Criminal Justice: Rethinking the Connection between Jails and Community Health, Issue Paper.