Strengthening Behavioral Health care Presentation to : Health, Welfare and Institutions Committee

1. Strengthening Behavioral Health care Presentation to : Health, Welfare and Institutions Committee Virginia House of Delegates July 30, 2007 Dr. Lawrence Goldman VP, Strategic Planning

2. We Are the Industry Leader in Managed Behavioral Health, with a Focus on the Public Sector • Founded in 1986, with headquarters in Norfolk and Reston • Privately held and physician-owned • Committed to principles of recovery • Diverse client base – over 24 million lives • Employer Solutions Division covering 21% of Fortune 100’s • Health Plan Division with 26 health plan clients • Federal Division (TRICARE) with 3 Million lives • Public Sector Division with Government clients covering over 4 million lives in 12 states • We understand theunique challengesof serving in the Public Sector. • Programs designed to advance a public service agenda • Populations with different behavioral health issues and social supports • Real-time accountability to multiple stakeholders • Need to balance administrative economies of scale and customization • Programs must complement – rather than duplicate or disrupt – the existing delivery system

3. ValueOptions’ National Footprint Latham Troy Detroit Boston Trafford Trafford Trafford Trafford Trafford Hartford Colorado Springs Colorado Springs Colorado Springs New York City Topeka Topeka Reston Hamilton Topeka Norfolk Phoenix Phoenix Durham Virginia Beach Phoenix Santa Fe Long Beach Dallas Irving Irving Jacksonville Headquarters Tampa Service Centers Corporate Support Offices 24.7 million covered lives Total Locations - 20 > 1 million lives > 300,000 > 100,000 < 100,000

4. We Are the Industry Leader in Managed Behavioral Health, with a Focus on the Public Sector • Experience and innovation • Robust data management Support consumer-led initiatives, quality improvement, and integration of care Manage access and treatment for children and adolescents Meet diverse needs of rural counties • Customized programs to meet diverse needs Transition of Medicaid behavioral health to recovery-based model • Increased access and quality leading to demonstrable improvements Provide statewide utilization management and review Improve care and support for Medicaid-eligible children and families Target broader issues like homelessness that are related to behavioral health Bring technology and care management to bear for at-risk children • Minimizing disruption and mitigating risks Coordinate and manage behavioral health care and an innovative pharmacy program Blend 17 funding streams to enable an integrated service delivery system Partner with providers to improve breadth and quality of care • Responsiveness – providing access to our senior decision-makers • Cost-effective and operationally efficient programs

5. Scope of Mental Health Problem • Headlines • Washington Post, July 17, 2007 • “In addition to a call for more funding, the most immediate changes probably will address laws that oversee how those with mental illnesses are monitored after they receive community-based services. Such people often do not need to be in a hospital but need to stick to treatment, which could include medication, therapy or both. Many mental health experts and lawmakers have said the state's oversight of people in this category is lax and the law is not specific enough to address those who do not comply with court orders…” • Roanoke Times, May 25, 2007 • EDITORIAL: Fix the fractured mental health system: Virginia mental health officials and the ill need unified standard procedures. • The Virginia Pilot, March 2, 2006 • Virginia gets a D in mental health services

6. Scope of Mental Health Problem • Kaiser Commission reported* • Increased public cost when mental illness is not treated • 20% of the US Population is some form of mental health disorder • 5% have serious mental illness such as schizophrenia, major depression, etc. * Profiles of Medicaid's High Cost Population - December 2006

7. Improve broader social and public health • Untreated or poorly managed behavioral health problems have serious social repercussions. • This a key strategy to • Improve broader health issues • Reduce the cost of other social services Source: World Health Organization, “Investing in Mental Health,” 2003

8. Mental disorders are the leading disability in the US among those 15-44 Mental illness results in more than 4 million lost work days and 20 million work cutback days each year in the US A third of those who are homeless have a mental disorder, and more than half suffer from substance abuse The majority of people who commit suicide have a mental disorder, with estimates above 80% In 1998, 16% of those in state prisons and local jails were mentally ill Alcohol was involved in 39% of fatal car crashes in 2004 Patients with depression are 3x more likely not to comply with medical regimens The Social Cost of Poor Treatment Is High • Untreated or poorly treated problems... • ...Produce tremendous social costs. • Cost of Mental Health • Absenteeism • Job loss • School drop-out • Injuries/Accidents • Suicide (Source: U.S. Surgeon General) • Incarceration • Gambling • Poverty • Homelessness • Crime $ Billions Note: Direct costs estimate from 1996; indirect from 1990 • Cost of Alcohol Abuse (Source: WHO) $ Billions

9. Public Sector Programs • Customized solutions • Tailor program & administrative strategies • Technological innovations • Integrated IS to track/report across funding streams • Web-enabled systems for real time decision support and inter-agency planning • QM programs • Flexibility • Responsiveness to consumers and family members

10. Key strategies… • Engage providers, consumers and family members • Oversight, • Design & implementation • Use evidence based practices • Facilitate inter-agency collaboration • Monitor improvements and document outcomes • Create provider incentives • Accurate and timely claims processing

11. And some results are… • Increased access to services • Expanded roles of and relationships • Involvement in program design • Increased satisfaction • Savings that have been reinvested in the behavioral healthcare system …and some examples are…

12. Integrate With and Improve Physical Health Care… • Situation: Some members in the Massachusetts program are too ill to seek needed care Essential Care Medical Care Management Program • Assigns each member a care manager who coordinates the services of the primary care clinician, behavioral health providers, state agencies, and community services, etc. • Program has grown to serve over 740 members from July 2005 to present • Impact: Participant PMPM medical costs reduced from $798 to $648 • A 2005 academic study found that enrolled members: • Received more targeted, integrated medical and behavioral health care, with increased access to primary care • Improved on both the mental- and physical-related physical functioning scores on a standardized tool • Increased compliance with behavioral and physical care • Required less acute and emergency care services • Before Enrollment • After Enrollment Source: Study conducted by the Center for Health Policy Research (CHPR) at the University of Massachusetts Medical School

13. $1,200 $800 $400 $0 During Pre Post CC Jan 02-Mar 02 (n=50) ICM Jan 02-Mar 02 (n=183) CC Apr 02-Jun 02 (n=103) ICM Apr 02-Jun 02 (n=198) Integrate With and Improve Physical Health Care… • Situation: Statewide in Massachusetts, many PCPs did not know how to treat, screen, and refer patients with behavioral health issues Impact on Children • Surveys show that PCPs participating in MCPAP report that they are now able to meet the mental health needs of children and adolescents in their practices • Program was implemented in FY05; 34% of pediatric practices were enrolled by September 2005.  Full statewide PCP participation is expected by end of FY06 Care Management Decreases Physical Health Costs Massachusetts Child Psychiatry Access Project (MCPAP) • Teams of child psychiatrists, social workers, and care coordinators provide psychiatric telephone consultation to PCPs within 30 minutes • Consultation guides PCP to the appropriate level of care based on the member’s needs Other MBHP Initiatives • Regional staff visit PCC Plan offices bi-annually to ensure that primary care staff know how to access behavioral health services and have a good relationship with a behavioral health provider • MBHP places care managers in primary care offices to serve members with depression • PMPM Cost Care Management Period

14. State policy decisions play a major role in determining the nature and breadth of programs... The More Inclusive the Program, the Wider Its Impact Housing Jail Diversion Coordination with Physical Healthcare Support for the Child Welfare System Pharmacy Management . . .the more broadly they are conceived... . . . the more opportunities they provide for social impact.

15. …And a Range of Program Designs • Single Funding Stream (e.g., Medicaid) • People enrolled and services covered are those funded through a single funding source • Colorado, Florida, North Carolina, Pennsylvania • Dual Funding Streams (e.g., Medicaid, MH, Child Welfare) • Two or more agencies jointly contract for services or create inter-agency agreements to coordinate service delivery through single vendor • Massachusetts, Connecticut, New Jersey • Integrated Systems of Care • Multiple agencies braid or blend programs and funding streams with a vision of reducing barriers, reducing admin costs, and creating a unified delivery system • New Mexico, Arizona, Texas NorthSTAR

16. Meet your Specific Objectives…

17. Reinvest Savings to Improve the Delivery System

18. VIRGINIA • Community Service Board System • Right reasons, right mandate • Community based services • Provides emergent, residential and preventative • Needs (as reported to this committee) • More trained professionals • Increased training opportunities • Quality improvement and data analytics • Increased connectivity

19. The Virginia Solution • States have turned to the private sector • Need cohesion in the system with all stakeholders • Private sector partnerships in other states have been effective • Tools to consider are: • Bed Tracking (especially residential) • Primary Physician Outreach • Outcomes measurement and Quality improvement • Jail Diversion

20. The Virginia Solution • System Integrator • Linkage between CSB and DMHMRSAS • Maintain CSB gateway • Tracking entry into the system • Analyze resources needs and allocation • Expand outreach based on determined need • Outcomes, quality • Expanded IT capabilities • Expanded toolset • For the delivery system • For the Department

21. Collaboration • Along all stakeholders • Increased system communication • Efficiency, allows maximizing Federal matching funds • Savings generated create re-investment opportunities

22. Conclusion • The enemy - status quo • The challenge - embrace change • The solutions • engage the private sector • build a bridge between the system and the government • amplify stakeholder involvement • bring new technology • create a reinvestment opportunity and strategy

23. Thank you Thank you for your time and interest….ValueOptions looks forward to working with you to build the new future for Virginia…. Dr. Lawrence Goldman larry.goldman@valueoptions.com 757 474 3204