Transcript Managing Entities: - Florida Alcohol and Drug Abuse

DCF Behavioral Health
Contracting and Reimbursement:
Current State Policy,
Impact in Communities
Lucia Maxwell, FADAA
National trends in health care
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Consumer choice
Least restrictive (costly) service setting
Pre paid reimbursement
Provider networks
Quality benchmarks (data for consumers
to compare provider performance)
Information Technology (EHR - electronic
health record)
Lucia Maxwell, FADAA
National trends in public policy Chemical Dependency, Mental Health
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Recovery emphasis; client-centered
service planning
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Systems of care, not silo-ed agencies
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Proven practices, performance
measures
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Continuous Quality Improvement (IT)
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Pre-paid per capita and case rate
reimbursement; Medicaid reform
Lucia Maxwell, FADAA
Implications for the field:
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Practice patterns changed – consumer
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Real community wide planning
friendly, shorter LOS. less residential & more
Intensive Outpatient, focus on internal agency
systems improvement
access, client pathways, responsiveness to
stakeholders
 Managed care capacity: reserves, preauthorizations, provider profiling, individual
and aggregate client data
 Inter-agency partnerships for services
planning, and to share costly systems and
financial risk
Lucia Maxwell, FADAA
What part of managed care
does DCF want?
Fewer contracts (now over 480 statewide)
 Assure best practices
 Data to measure performance (provider
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profiling)
Flexible payment to match client to
needed services (pre-paid)
 Predictable budget, incentives for
efficiency and access (pre paid)
 Increase client access and # served
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(reduce waiting lists & unmet needs)
Lucia Maxwell, FADAA
DCF Assumptions
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Providers working together will create a system of
coordinated services which better meet client needs.
 Providers can collaborate to share the costs of staff,
IT, & training.
 Providers as partners can spread the financial risk of
pre paid reimbursement.
 Staff of a provider network will monitor services to
assure best practices and improve outcomes, and will
prepare reports for the state to review.
 Both clients and community stakeholders can access
a network easier than independent agencies.
Lucia Maxwell, FADAA
History of DCF Managed Care Initiatives
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CSAT report 2000: networks, care management
 Commission on MH/ SA: need system changes in contracting, financing
 SB 1258 (2001): quality/ best practices, data for planning, risk sharing/
control costs, flexibility to fit payment to service needs. PILOTS
 SB 2404 (2003): DCF/ AHCA jointly develop all policy, budgets,
procurement procedures, contracts and monitoring common service
definitions, standards and accountability mechanisms
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2003: DCF can establish new data systems and fee for service, prepaid capitation or pre-paid case rates by administrative rule.
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HB 1843 (2004): Medicaid pre-paid expanded statewide
 Late 2004: Single ME paper: DCF contract with Medicaid contractor
 “System conversion” work groups 2005 – 2006: specifications for
Managing Entity contracting
Lucia Maxwell, FADAA
Most recent State policy actions
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No new funds for Managing Entity
infrastructure development (only agency
contributions & direct service dollars)
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DCF Secretary Hadi wants client centered
planning for ME development
 Community determination of ME structure:
provider network, district office or lead agency
as managing entity
 DCF is planning for case rate reimbursement,
beginning with methadone.
Lucia Maxwell, FADAA
Florida Statues say
DCF may contract with:
A single managing entity or a provider
network in each area or region
 A “managing entity” is defined as:
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1. A network of existing providers with an
Administrative Services Organization that
can function independently
2. An ASO that is independent of local provider
agencies, or
3. An entity of state or local government.
Lucia Maxwell, FADAA
At this time, DCF managed care policies
preserve non-profit, community based
systems of care and traditional providers
Take note: If this is not successful,
the State could contract with for profit
Managed Care Organizations
(selective contracting, for profit providers,
cost reduction objectives primary.)
Lucia Maxwell, FADAA
What are the options for
ME organization?
District office could retain the authority
 A lead agency could be chosen:
County government? A large
community mental health center?
 Prepaid mental health plan as SME
 Provider network with a staff (ASO)
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Lucia Maxwell, FADAA
State Managing Entities
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Northeast Florida Addictions Network – SA only
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) – SA only
Lakeview as lead agency in district #1 contracts for
DCF, Medicaid and CBC revenue – SA/MH.
Lucia Maxwell, FADAA
Successful communities will
have network leaders who
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are wiling to enforce standards of care
represent ALL service recipient
communities (racial/ ethnic minorities)
work well with local government for
coordinated planning, financial support
attract local philanthropic support
are willing to change services and
practice patterns to improve system of
care.
Lucia Maxwell, FADAA
Network challenges
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Leaders who are “historical preservationists, ”
slow to change practice patterns, can’t give up
single agency focus, focus on competition over
collaboration, lack client orientation
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Working together to build trust over time,
overcome traditional rivalries, be willing to
undergo peer review
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Power in the network comes from performance,
market position, leadership in the larger
community, $ contribution to infrastructure
costs.
Lucia Maxwell, FADAA
Unresolved issues
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Will competitive bidding be required: areas
without networks? areas with established
networks?
ME required functions and capacities: what
are we willing to pay for?
Consumers and stakeholders on ME Board?
ME contracts: outcome or process driven?
Coordination with Medicaid and with MH
Linkages with HMOs, PMHPs, CBCs
Lucia Maxwell, FADAA
In communities where agencies
have formed networks/ MEs
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Providers together accept responsibility for
meeting performance objectives (DCF
services)
 DCF performance standards begin to shift to
system wide objectives: e.g. reduce waiting
lists; increase services to children
 The State continues to transfer authority and
money
 Providers have assurances and can make
long range plans.
Lucia Maxwell, FADAA
Environmental conditions which will
influence future policy
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Continued strong support for MEs from 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.
Limitations of AHCA and DCF staff time and
resources
Changes in State Administration:
Governor’s office, DCF, AHCA
Lucia Maxwell, FADAA
Medicaid Substance Abuse
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Nowhere in the state is Medicaid substance abuse
capitated today.
When Medicaid reform demos are concluded in 2008,
sub abuse may be added to MC contracts.
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Prepaid MH Plans are not eligible contractors under Medicaid reform,
only Health Maintenance Organizations (HMOs) and hospital/ physician
Provider Service Networks (PSNs) . .
 HMOs and PSNs could subcontract sub abuse (and mental health)
services to DCF Provider Networks and MEs.
 DCF Managing Entities could negotiate higher rates by assuming some
of the managed care functions (credentialing, QA/ QI, authorizations.)
 Alternative policy for Medicaid sub abuse ($12 m statewide): AHCA
contract with DCF to manage the care.
Lucia Maxwell, FADAA