Transcript Integration under ACA: Carving-in or Carving-out

Mental Health America’s
Regional Policy Council
Forum at the National Press Club
Washington, DC
December 12, 2003
Charles Curie,
The Curie Group, LLC
Presenter
“I Love it when a plan comes together !”
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HealthPass in Philadelphia (demonstration model).
Voluntary Managed Care in Southeast.
◦ Physical Health Managed Care Organizations subcontract for BH services.
◦ “Third Leg of Profit;” money did not reach individual; huge profits.
◦ Philadelphia Inquirer expose.
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Primarily FFS in remainder of state.
◦ Integrated; all FFS.
◦ No care management.
◦ Increased costs.
◦ No coordination.
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Setting the stage for HealthChoices.
◦ Ridge Administration, legislature/bi-partisan support and implementation of
Behavioral Health/HealthChoices.
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• State Plan Services, cost-effective alternatives and
supplemental services available.
• Consumer/Family Satisfaction Team (C/FST) in every
contract.
• Reinvestment of savings at the local level; must be
committed to behavioral health and targeted to
Medicaid population.
• Performance measurement system.
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Program is statewide; 10 years to fully implement.
BH program began in 1997; phased in through 2007.
─ 43 counties (joinders/multi-counties) accepted the right of first opportunity;
mixture of ASO and county risk-sharing arrangements.
─ 23 counties (rural): state contract; 1 county (southwest zone): state contract.
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Five current BHMCO contractors/subcontractors.
Unified systems strategy to support programs across
all funding streams, including closure of state
hospitals, and children in dependency, delinquency
system.
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• Increase access.
• Improve quality of services.
• Stabilize Medicaid funding.
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Managed program costs below anticipated fee-for-service
trend; administrative costs are low.
◦ Four billion dollars in savings.
Continues to serve more people and has maintained a focus
on those with the most need.
◦ Access exceeds national benchmarks for persons with
serious mental illness.
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Continues to provide a wider array of services in less
restrictive settings.
◦ Increased drug and alcohol provider network by over 500
programs.
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Reinvestment opportunities have sparked innovative practices
and cost effective alternatives to current practices.
◦ Less restrictive alternative services increased by 400%.
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Increased the number of people served.
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Maintained commitment to serving persons
with serious mental illness.
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Provider networks expanded; able to access
beyond county/state borders.
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Drug and alcohol services increase as
program matures.
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Responsive cost effective alternative services
(supplemental) developed.
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In PA, role of county government has been
critical to the success of the program.
C/FSTs feedback increasingly influencing local
systems.
Extensive QM program; identify barriers and
implement performance improvement.
Innovative program development has occurred.
Performance Base Contracting project report
allows statewide comparisons.
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Rate Setting
– Methodology updated as program matured.
– Incorporated risk-sharing arrangements in new zones
to increase financial predictability.
– Moved from FFS data to MCO encounter data to reflect
program’s managed care experience.
• Encounter data allows for detailed analysis required by
initiatives such as provider profiling, supplemental
services, and program dashboard.
– Explicit profit/reinvestment component is not built
into the rates, rather profit/reinvestment is gained via
efficient care management or other program
efficiencies.
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Contracted Rate Vs. Projected FFS
$180.00
$170.00
$160.00
$150.00
$140.00
$130.00
$120.00
$110.00
$100.00
$90.00
$80.00
$70.00
$60.00
1996 1998 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Medical Contracted Rate $87.1 $64.4 $61.5 $69.7 $81.6 $89.0 $94.0 $91.9 $92.0 $103. $109. $112. $116.
Projected FFS
$87.1 $91.9 $97.0 $102. $107. $113. $120. $126. $133. $141. $148. $157. $165.
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FFS (1998)
2008
2%
6%
4%
12%
16%
IP
IP
5%
9%
46%
13%
BHRS
19%
OP
OP
RTF
13%
D&A
RTF
D&A
18%
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BHRS
15%
22%
CSS
Other
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“As we consider how to realize the
integration of behavioral health services with
general healthcare, we need to be careful not
to rush to integrated care without
thoroughly considering what we want to
gain and clearly identifying what we do not
want to lose.”
Charles Curie
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People with behavioral health conditions are at higher
risk for physical illness and disability, and the cost of
medical care for them is, on average, much higher than
the cost of medical care for people without behavioral
health conditions (United Hospital Fund in New York
City report).
Medicaid recipients with mental health conditions are
30-60% more likely to have hypertension, heart disease,
pulmonary disorders, diabetes, and dementia.
People with substance abuse conditions are 50-300%
more likely to have heart disease, pulmonary disorders,
and HIV/AIDs.
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Behavioral health is a part of overall health;
good health outcomes are important to an
individual’s recovery.
Integration of good health habits,
prevention activities, and specific physical
health interventions are best achieved
through local collaborations and navigator
systems.
Good health outcomes can be achieved
within the existing PA behavioral health
system design.
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Projects supporting integration of services
and supports for individuals with physical
health (medical) and behavioral health
needs happening across the state in urban,
rural, and suburban settings.
Co-locations; collaborations; shared staff
models; health home development; shared
health records.
PA collaboration with the Center for Health
Care Strategies.
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HealthChoices Health Connections
• An innovative model to better integrate
physical and behavioral health care for the
identified population.
• Demonstrate outcomes improvements.
• Reduce health care costs.
• Document the process for replication.
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14 Essential Elements of - IHH
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Fully
integrated
service model
Shared
continuity of
care record
Specialized
chronic care
improvement
program
Recipient
voice and
participation
Family
support and
engagement
Self-mgmt
tools and
education
Self-advocacy
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Early and Enhanced
Shared
Collaboration
Governance &
Accountability
Voice and
Participation
Living
Healthy
Working
Well
Prevention and Early
Intervention
Shared
governance
 Shared
resources
allocated by
level of risk
 Outcome and
System
Efficiency
tracking
 access to
BH and
primary care
 Routine
screening and
prevention
 Whole health
peer supports
 Strengthsbased services
and language
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Magellan Health Services, Inc. | 18
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Children & youth are being treated with psychotropic
medications that have only been approved through clinical
trials with adults.
Children and youth are still developing. Little is known about
the impact of medications on their development.
Many children & youth are taking multiple medications
without benefit of positive outcomes. The use of multiple
prescriptions increases the likelihood of drug interactions and
other adverse effects.
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Side effects include weight gain, cardiovascular disease,
insulin resistance, neurological and other issues.
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Medications can prevent the development of psychosocial
strategies and interpersonal skills.
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Inappropriate use of medications can lead to false
expectations from family, school personnel, and other
caretakers.
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Children & youth die as the result of
inappropriate psychotropic medication
Psychotropic meds have become a new source
of supplemental income
Psychotropic meds are related to crime &
violence
Psychotropic meds may be treating the
prescriber rather than the patient!
The issue is everybody’s business!
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Should primary care physicians be required to obtain
a second opinion from a child psychiatrist or
psychiatrist before prescribing psychotropics to
children or youth?
Should health plans be required to institute prior
authorization for prescribing psychotropics to kids?
Should off-label prescribing be prohibited entirely?
Can health plans be required to monitor off-label
prescribing of these medications?
Can pharma be required to produce easy-tounderstand guides for parents regarding
medications?
Could medical boards require courses in
psychopharmacology and mental health first aid as a
requirement for license renewal?
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Structure of accountability addressing the
needs of people and children with the most
serious and persistent disorders
Access to quality, appropriate care
Implementation of evidence-based services
Cost containment = sustainability
Learn from BHMC carve-outs
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