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

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

2

The PA Story, in the beginning…

“I Love it when a plan comes together !”

The Curie Group, LLC, December 2013

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.

Primarily FFS in remainder of state.◦ Integrated; all FFS.◦ No care management.◦ Increased costs.◦ No coordination.

Setting the stage for HealthChoices.◦ Ridge Administration, legislature/bi-partisan support and implementation of

Behavioral Health/HealthChoices.

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In the beginning….


• 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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HealthChoices Program:Key Features


• 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.• 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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HealthChoices Today


• Increase access.

• Improve quality of services.

• Stabilize Medicaid funding.

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HealthChoices Goals


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. Continues to provide a wider array of services in less

restrictive settings. ◦ Increased drug and alcohol provider network by

over 500 programs. Reinvestment opportunities have sparked innovative

practices and cost effective alternatives to current practices.◦ Less restrictive alternative services increased by

400%. 7

Pennsylvania Behavioral HealthHealthChoices Program


Increased the number of people served. Maintained commitment to serving persons

with serious mental illness. Provider networks expanded; able to access

beyond county/state borders. Drug and alcohol services increase as

program matures. Responsive cost effective alternative services

(supplemental) developed.

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Improving Access


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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Improving Quality


• 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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Financial Management


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HealthChoices Savings

1996 1998 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 $60.00

$70.00

$80.00

$90.00

$100.00

$110.00

$120.00

$130.00

$140.00

$150.00

$160.00

$170.00

$180.00

Contracted Rate Vs. Projected FFS


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Systems Redesign

46%

18%

19%

5%

6%4%

2%

FFS (1998)

IPOPBHRSRTFD&ACSSOther

16%

13%

22%14%

13%

10%

12%

2008

IPOPBHRSRTFD&ACSSOther


“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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Integration??


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 are30-60% 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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What are the facts?


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Physical /Behavioral Health

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.


16

Physical /Behavioral Health 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.


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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Integrated Care in Pennsylvania


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BH Driven Integrated Health Home

Magellan Health Services, Inc. | 18

Fully integrated service model

Shared continuity of care record

Specialized chronic care improvement program

access to BH and primary care

Routine screening and prevention

Whole health peer supports

Strengths-based services and language

Shared governance

Shared resources allocated by level of risk

Outcome and System Efficiency tracking

Recipient voice and participation

Family support and engagement

Self-mgmt tools and education

Self-advocacy

Voice and Participation

Shared Governance & Accountability

Early and Enhanced Collaboration

Living Healthy Working

Well

Prevention and Early Intervention

14 Essential Elements of - IHH


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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.

Side effects include weight gain, cardiovascular disease, insulin resistance, neurological and other issues.

Medications can prevent the development of psychosocial strategies and interpersonal skills.

Inappropriate use of medications can lead to false expectations from family, school personnel, and other caretakers.

BHMCO Focused Problem Solving: Children & Psychotropic Drugs

19The Curie Group, LLC, December 2013

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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!

The Issue, continued…

20The Curie Group, LLC, December 2013

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Action Item:


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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-to-

understand guides for parents regarding medications? Could medical boards require courses in

psychopharmacology and mental health first aid as a requirement for license renewal?

Is legislation a help or hindrance?


23

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

Specialty BH Managed Care


integration under aca: carving-in or carving-out ?

Documents

accessthe curie group

charles curie

alcohol services

state plan services

key featuresthe curie

bh services

quality of services

managed program costs