Transcript Document

DCF System Conversion
and Medicaid Managed Care:
The impact on provider
contracting and reimbursement.
7/16/2015
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DCF plans “system conversion”
within two years
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A managing entity will be selected by competitive bid
for each district or region.
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DCF will contract for SA and MH services with the
Managing Entity rather than directly with providers.
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The role of district office staff will change to that of
“Purchaser.”
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Parts of the DCF data system may be outsourced.
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NO changes in local match: amt, sources, ratio
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What are DCF’s goals for the redesign?
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Recovery oriented services, individualized
treatment
Customer driven services
Systems of care, not “silo-ed” agencies
Assure best practices
Quality improvement
More flexible funding
Reliable data system
Preserve local $ contributions.
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What is a Managing Entity?
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As defined in Florida Statutes:
1. A network of existing providers with
an Administrative Services Organization
(ASO) that can function independently,
2. An ASO that is independent of local
provider agencies, or
3. An entity of state or local government.
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What is a Managing Entity?
In practice:
 A group of providers establish a new corporation
which will contract with the State. Providers become
subcontractors.
 The new corporation hires staff (contracting, finance,
IS, monitoring, QA/QI, technical asst., outreach?) to
develop protocols and procedures which build
separate services into a system of care.
 Capacities are built slowly over time. As trust
develops, the dialogue among providers moves from
resource allocation to improving access,
responsiveness and quality.
 CQI focuses on system goals, not agency goals (e.g.
reduce days to service, improve placement and
retention.)
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What will be the new role of district
office staff?
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Negotiating and monitoring a single contract for a
services system.
Setting CQI measurable system goals for the
Managing Entity to achieve (increase women’s
services, decrease waiting lists, improve workforce
development activities, increase detox capacity.)
Enhanced focus on community planning.
Build systems for determining stakeholder
satisfaction with ME operations.
Develop mechanisms to ensure that services design
and service delivery are consumer driven.
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Managing Entities are forming
in many districts.
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South Florida Provider Coalition (#11)
- SA/MH
Southwest Florida Behavioral Health (#8) - SA/MH
Central Florida Behavioral Health Network (#5, #6,
#14) - SA/MH
Premier Services Network (district #7)
Northeast Florida Addictions Network
(#4, #12, possible North Florida expansion?)
Lakeview as lead agency in district #1 contracts for
DCF, Medicaid and CBC revenue – SA/MH.
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Implicit assumptions in DCF redesign.
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District offices do not have the resources to take on
these tasks.
The system is provider driven, so providers must take
responsibility to build systems of care.
Managing Entity administration will be financed with a
percentage of services dollars (likely 4% – 8%.)
Slow conversion from unit cost contracting to prepaid
financing. Capitation unlikely, possibly case rates.
Not an insurance model, but better definition of
eligibility for DCF services (by income, diagnostics.)
DCF goal is cost efficiency not cost containment.
MCO partnerships are not necessary in most areas.
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Unresolved issues
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Degree of local determination:
e.g. ME structure, single point of access, consumer
advisory bodies
Governance requirements (e.g. Board composition)
ME contracts: outcome or process driven?
How to realize the goal of “braiding” Medicaid and
DCF funding.
How DCF Managing Entities will coordinate care with
HMOs, PMHPs, the CBC specialty network
Role of Managing Entities in contracting for Medicaid,
JJ, Corrections funding
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Environmental conditions which will
influence the initiative.
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Continued strong support from current DCF
leadership.
Provider initiative to form networks and
develop Managing Entity capacities.
DCF re-tooling: staff training, capacity to
monitor outcome based & prepaid contracts.
Future status of Medicaid Prepaid Mental
Health Plans.
Mental health provider focus.
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Medicaid managed care
2005 – 2008?
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Prepaid Mental Health Plans for Medipass clients selected for
areas 1, 5, 6, 7 and under review for 2,3, and 4; AHCA will bid
remainder by July, 2006 except possibly Dade County.)
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Two PMHPs are partnerships between Value Options and area
Community Mental Health Centers; Lakeview in district one.
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Medicaid HMOs adding mental health after AHCA approves their
network of providers; most direct contracting as opposed to
behavioral MCO subcontract.
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Medicaid substance abuse is likely to be added to these plans in
2006; some possibility that Medicaid could contract for sub
abuse with DCF managing entities.
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BHOS, SIPP waiver, foster group care exempt.
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Community Based Care
Medicaid Specialty Network
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RFP announced to select a lead community based
care agency to contract for all Medicaid mental health
services for HomeSafeNet children.
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Sub abuse services are not included now.
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The CBCs have formed a statewide organization and
selected a Managed Care partner to bid on the
contract.
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The statewide contractor will subcontract for all
services with local CBCs.
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Local CBCs may deliver the services or contract with
mental health service agencies.
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Evaluation of System Changes:
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SA/MH Corporation will establish criteria and
baseline data to measure impact of system
changes, for reports to Legislature (sunsets
October, 2006 if not reauthorized)
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By December 31st, FMHI evaluation of pilots:
recommendations and a timetable,
milestones, and date certain for
implementation of successful strategies
statewide.
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Medicaid reform
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Medipass and Prepaid Mental Health Plans are not
mentioned in the reform law (SB 838)
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The law says Medicaid will contract only with plans or
networks which provide physical, behavioral and
pharmacy services to their members.
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AHCA’s 1115 waiver application to the feds (CMS)
will be posted on the web for review within the month
(Legislative review but not approval.)
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Medicaid reform demos begin 2006 - 2007 in
Broward and Duval; expansion to other counties is
contingent on Legislative approval.
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Changes defined benefit to defined contribution.
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Provider Sponsored Networks
and Medicaid reform
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Networks or their Managing Entities may
contract with the Health Maintenance
Organizations (HMOs) and Provider Service
Networks (PSNs) proposed under Medicaid
reform, for the community behavioral health
services to be offered in plans.
 Managing Entities can negotiate higher rates
by assuming some of the managed care
functions (credentialing, QA/ QI,
authorizations.)
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Medicaid Substance Abuse
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Nowhere in the state are Medicaid substance abuse
services capitated.
 Medicaid payments for substance abuse statewide
are less than $15 million, 1/3 to ½ to hospitals.
 Three new Medicaid codes authorized for counties
willing to use local dollars as match: community
detox, intervention, aftercare. No state GR.
 Services financed with local dollars will never be
contracted to Managed Care Organizations.
 Contact your county staff about participation. More
info: [email protected]
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What options do providers have?
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Build or join a Provider Sponsored Network in your
district or region (owner.)
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Decline to participate in Managing Entity governance,
but seek to contract with the Managing Entity in your
area. (subcontractor.)
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Negotiate a partnership with another agency which
owns or contracts with a Managing Entity (merger.)
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Contract with the MCO which receives the DCF
Managing Entity contract for your area, if no
community based ME is formed by local providers.
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