Spring Policy Forum Spring Policy Forum

System Redesign System Redesign –– What’s In It For All?What’s In It For All?

David R. Swann, MA, LCAS, CCS, LPC, NCC

Area Director & CEO

Crossroads Behavioral Healthcare2012

• For Consumers

• For Providers

• For Managed Care Organizations

Better Care Must Be the End Game

• For Managed Care Organizations

• For Government Payers (County, State and Federal)

• Accrediting Organizations

2

3

• The policy vessel is being steered by:

�Government funding

�Policy implementation by non-governmental

payers

Better Care Through Policy

payers

�Accrediting organizations

�Accountability expectations

�Research (chronic disease management,

standards of care, innovative treatment options,

use of technology)

4

� Escalating costs

� Shrinking Revenue

� Calls for accountability

� Pressures from stakeholders (patients, providers,

Health Care Reform:

Understanding the Context

5

� Pressures from stakeholders (patients, providers,

payers, etc.)

� Health care reform offers the opportunity to build

from local strengths to meet the challenges

� Health Homes and Accountable Care Organizations

are tools permitted to achieve the goals

1. As parity and national healthcare reform are implemented, more people than ever before

will have access to treatment for mental health and addiction services through expanded

public and private insurance coverage.

2. Specialty behavioral healthcare organizations must expand capacity to meet increased

demand and offer measurable, high-performing prevention, early intervention, recovery,

and wellness services and supports.

3. We must also be ready to work with the expanded Medicaid systems and be able to bill

Why A System Redesign? Improved Access,

Better Care, Potentially Reduced Costs

6

3. We must also be ready to work with the expanded Medicaid systems and be able to bill

through the new health insurance exchanges, Accountable Care Organizations (ACOs),

Primary Care Medical Homes, Person-Centered Medical Homes and other funding sources.

4. “Medical Homes” and “Health Homes” are becoming the primary focus of integration of

care – connecting the head back to the body…

5. Significant movement to “One Stop Shops” integrated healthcare service delivery models.

• Access� Services earlier on

� No show management

� Same day access

� Reduced time from first call to treatment

• Outcomes

Global Policies and Strategies to

Improve Behavioral Healthcare

� Same day access

� Engagement strategies

� New models of care (integration, coordinated care, ACOs, Specialty care, health homes)

• Costs� Value based purchasing (pay for performance, episodes of care)

� Rates

� Collaborative documentation

� Maximizing capacity

7

1. Prevention and Wellness Focused

2. Managed Care (2012 Version)

3. Integrated “Horizontal” Care Delivery System

4. New Integrated Management Entities for Medicaid and

Medicare Funding:

Key Key Policy Drivers Policy Drivers of a “Reformed” of a “Reformed” Healthcare Healthcare

System To Address Outcomes, Access and CostsSystem To Address Outcomes, Access and Costs

8

Medicare Funding:� Accountable Care Organizations - Medical Center and Primary Care Practice Partners with

specialty providers under contract for service delivery

� Health Homes, Health Home Neighbors - Population-based integrated care model

targeting consumers with chronic conditions, which coordinate medical and behavioral

health care, and community and social supports

� Primary Care Medical Homes - Coordinated care model focused on acute care for all

populations

� Care Coordination to improve care

� Payment Reform – Primarily shared risk

models with incentive payments to

providers for meeting quality outcome

indicators

Key Policy Drivers of a “Reformed” Healthcare Key Policy Drivers of a “Reformed” Healthcare

System To Address Outcomes, Access and CostsSystem To Address Outcomes, Access and Costs

indicators

� Technology (EHR, Meaningful Use,

Telemonitoring, Telemedicine)

9

Federal and State Policy

Initiatives to Achieve Better CareInitiatives to Achieve Better Care

Medicaid Managed Care Systems

• Certain types of Medicaid Managed Care waivers are designed to manage the growth of Medicaid funding while, at the same time, maintaining high quality behavioral healthcare benefit plans.

• The objective is not to limit services for individuals, but to manage a system so that a person is guided to the

Medicaid 1915 B and C Waiver –

Prepaid Inpatient Health Plans

manage a system so that a person is guided to the appropriate level of care.

• 35 States currently operating Managed Care Waivers

• Medicaid managed care to control costs and to expand the

use of disease and care management programs and patient-

centered medical homes to coordinate care for high cost and

high need populations

11

• Controlling the selection of the professionals

and provider organizations in a particular

delivery system

• Setting service payment rates and

Medicaid Managed Care – MCO

Responsibility

• Setting service payment rates and

methodologies

• Setting clinical best practice policies

• Establishing the framework for the

measurement of clinical quality and

performance12

• New Hampshire, Alaska and Wyoming are the only three

states without some Medicaid managed care.

• Behavioral Health Carve Out Model with Health Homes are

being tested in several states (MO, RI, AZ, IA, OH, KS)

Medicaid Managed Health Plans

being tested in several states (MO, RI, AZ, IA, OH, KS)

• Many states are moving ‘disabled’ populations (including

populations with SMI) from fee-for-service financing model to

a managed care financing model.

13

• 1.3 M Medicaid enrollees, 80% are enrolled in the CCNC

Medical Home program.

• $984 M in savings between 2007 and 2010.

• Cost for persons “aged, blind or disabled” remained constant

over the 4 years.

Community Care North Carolina Where Policy and

Strategy Delivered Better Access, Better Outcomes and

Reductions in Cost

over the 4 years.

• Care is focused on enrollees with complex health problems.

• Care Coordination function at Health Home and Care

Management at Systems level is used to improve care and

reduce cost.

• Care Coordination for behavioral health began in 2010

14

• Pennsylvania example: Behavioral Health Choices generated

$4 billion in savings from 1997-2007.

• Massachusetts example: A 50% reduction in ED visits and a

71% reduction in psychiatric admissions for Medicaid

enrollees over the 3-year period 2007-2010.

Managed Behavioral Health Organizations MBHO’s –

Quality and Cost Outcomes

15

enrollees over the 3-year period 2007-2010.

• Colorado example: MBHOs operating in CO for 14 years have

contained increases in their capitation rate to 13.8%, far less

than the inflation rate of 44% and the inflation rate of medical

care of 82%.

• Serving people in their communities reduces Medicaid costs

and leads to better outcomes for those served.

• North Carolina’s State Plan Amendment for the “i” Option

HCBS was submitted on April 30, 2012.

• Effective date January 1, 2013

Managed Medicaid 1915(i) Option

• Effective date January 1, 2013

• 1915(i) allows NC to provide some Medicaid services currently

available only through the CAP or Innovations Waiver to an

additional, specifically defined population. These additional

people must be determined to be Medicaid eligible.

16

Federal Policy Initiatives to

Achieve Better CareAchieve Better Care

Accountable Care Organizations

18

“Almost one fifth (19.6%) of the 11,855,702 Medicare

beneficiaries who had been discharged from a hospital were

re-hospitalized within 30 days…We estimate that the cost to

Medicare of unplanned re-hospitalizations in 2004 was $17.4

billion”

•Source: NEJM 2009;360:1418-28

• Coastal Carolina Quality Care, Inc. (CCQC), Accountable Care Coalition of

Caldwell County, LLC, and Accountable Care Coalition of Eastern North

Carolina, LLC, who were recently selected by the Centers for Medicare and

Medicaid Services (CMS) to participate in the Medicare Shared Savings

Program as an Accountable Care Organization (ACO) beginning April 1,

2012.

Accountable Care Organizations in

North Carolina

2012.

• Cigna, as a private health care insurer, is also expanding its collaborative

accountable care program by adding 10 new initiatives with physician

groups in seven states, including North Carolina’s Cornerstone Health Care

and Key Physicians (Key IPA).

19

Integrated Healthcare

“Values” Needed

Under an Accountable Care Organization Model the Value of Behavioral Health Services will depend upon our ability to:

1. Be Accessible (Fast Access to all Needed Services)

2. Be Efficient (Provide high Quality Services at Lowest Possible Cost)

3. Electronic Health Record capacity to connect with other providers

20

3. Electronic Health Record capacity to connect with other providers

4. Focus on Episodic Care Needs/Bundled Payments

5. Produce Outcomes!

• Engaged Clients and Natural Support Network

• Help Clients Self Manage Their Wellness and Recovery

• Greatly Reduce Need for Disruptive/ High Cost Services

1. What is the time between first call to

treatment?

Accountable Care Organization Key

Questions for Behavioral Healthcare

2. We have 454 (200 + with SMI, SPMI)

behavioral health patients assigned to our

ACO, how much time will it take them to all

get in and receive care?

21

The ACO Concept for SuccessThe ACO Concept for Success

• Accountable – 32 Performance Measures

• Innovative Care Redesign and Cost

Effectiveness

• Built Around Consumer

22

• Built Around Consumer

• Team-Based Care

• Aligned Incentives to achieve the Triple Aim

• Requires relevant, timely data

• Shared savings between the ACO and

Medicare Trust Fund

• CMS approved the 32 rules for ACO’s

• Shared savings based on Four Domains of

Quality:

– Quality of patient experience

Accountable Care Organizations

– Quality of patient experience

– Care Coordination and patient safety

– Preventive health

– At-risk populations

23

Federal Policy Initiatives to

Achieve Better CareAchieve Better Care

Health Insurance Exchanges (HIE)

• Final rules for HIE approved in March 2012

and begins in 2014

• The Network Adequacy Standards provisions

state that Qualified Health Plans must

Health Insurance Exchanges Policy

Development

state that Qualified Health Plans must

maintain a network of providers that is

sufficient in number and types of providers,

including providers that specialize in mental

health and substance abuse to assure that all

services will be accessible without

unreasonable delay25

• These qualified health plans will establish

rates for services

• Qualified health plans are required to

reimburse Federally Qualified Health Centers

Health Insurance Exchanges Policy

Development

reimburse Federally Qualified Health Centers

at the facility’s Medicaid prospective payment

(PPS) rate

• HIEs may be steered away from FQHCs due to

the higher rates and no ability to negotiate

26

Policy Initiatives to Achieve

Better CareBetter Care

Care Coordination

“

Mental Health Community Case Management

and Its Effect on Healthcare Expenditures”

• People with severe mental illness served by public mental health systems have rates of co-

occurring chronic medical illnesses two to three times higher than the general population,

with a corresponding life expectancy of 25 years less.

• Treatment of these chronic medical conditions comes from costly ER visits and inpatient

stays, rather than routine screenings and preventive medicine.

• In 2003, in Missouri, for example, more than 19,000 participants in Missouri Medicaid had

a diagnosis of schizophrenia. The top 2,000 of these had a combined cost of $100 million in

Missouri Medicaid claims, with about 80% of these costs being related not to pharmacy,

but to numerous urgent care, emergency room, and inpatient episodes.

28

but to numerous urgent care, emergency room, and inpatient episodes.

• The $100 million spent on these 2,000 patients represented 2.4% of all Missouri Medicaid

expenditures for the state’s 1 million eligible recipients in 2003.

By: Joseph J. Parks, MD; Tim Swinfard, MS; and Paul Stuve, PhD Missouri Department of Mental Health Source: PSYCHIATRIC ANNALS 40:8 | AUGUST 2010

29

• Total healthcare utilization per user per month, pre- and post-community mental health case

management. The graph shows rising total costs for the sample during the 2 years before enrolling in

CMHCM, with the average per user per month (PUPM), with total Medicaid costs increasing by over

$750 during that time. This trend was reversed by the implementation of CMHCM. Following a brief

spike in costs during the CMHCM enrollment month, the graph shows a steady decline over the next year

of $500 PMPM, even with the overall costs now including CMHCM services.

Source: PSYCHIATRIC ANNALS 40:8 | AUGUST 2010

C a r e C o o r d i n a t i o n

30

• Policy (Section 2703) requires Medicaid

enrollees to be enrolled in a care coordination

health home with integrated physical and

behavioral healthcare. Target population may

Care Coordination

behavioral healthcare. Target population may

be persons with MI/IDD/SA

31