Mental Health Transformation

1. 1 Mental Health Transformation Cathy Boggs, Director Division of Mental Health & Addiction Gina Eckart, Assistant Director Division of Mental Health & Addiction Caroline Carney Doebbeling, Director of Quality & Outcomes Office of Medicaid Policy & Planning May 13, 2008 Transformation Stakeholder Presentation OUR WORK FOCUSED ON WHAT YOU TOLD US AND WHAT WE LEARNED. OUR WORK FOCUSED ON WHAT YOU TOLD US AND WHAT WE LEARNED.

2. 2 Principles of Transformation Promote a more recovery-oriented service delivery system Focus on outcomes and improved quality of life Maximize resources and assure accountability Improve access to basic healthcare for persons with SMI, SED, and/or CA Align funding strategies with service expectations Transition from institutional entitlement to individual enfranchisement Discuss the process for the TWG: Reviewed transformation grant states. Talked with 7 state program directors. Worked with providers and consultants.Discuss the process for the TWG: Reviewed transformation grant states. Talked with 7 state program directors. Worked with providers and consultants.

3. 3 Drivers of Current System Breadth of population served limits depth of services to SMI Inconsistent use of evidence-based practices Service delivery driven by funding Under-utilized Medicaid coverage & Over-leveraged Medicaid utilization Lack of delivery system accountability Fragmentation of mental health and other healthcare delivery systems High uninsured rate among adults with behavioral health needs Based on feedback and data analysis we believe these are the drivers that lead to the suboptimal state of system today and as move look to move Forward must focus on addressing these drivers. We plan to go through some background and data today that highlights the results of these drivers And then look toward identifying solutions with your help & feedback.Based on feedback and data analysis we believe these are the drivers that lead to the suboptimal state of system today and as move look to move Forward must focus on addressing these drivers. We plan to go through some background and data today that highlights the results of these drivers And then look toward identifying solutions with your help & feedback.

4. 4 Low-income Population with MH Needs Receiving FSSA-funded MH Treatment Unduplicated member count Chronically Addicted represent another 29,979 in both Medicaid (4,412) and HAP (25,567).Unduplicated member count Chronically Addicted represent another 29,979 in both Medicaid (4,412) and HAP (25,567).

5. 5 Claims Expenditures for 6,500 Medicaid Patients With and Without MH/SUD Service Use Normalized on members without behavioral health claims at 100Normalized on members without behavioral health claims at 100

6. 6 Transition from outcomes/variability of service, quality to funding – goal to just describe current state. According to the Blue, Inc. report, 16-20% amount of CMHC’s budget which goes towards those requirements under their certifications which they are not reimbursed for. (Uncompensadted care) Discuss institutional entitlement leads to funding w/o strings and regardless of outcomes of service (patient can’t walk away and take revenue stream) Lack of historical performance measures, or expectations for quality, efficiency, etc. Transition from outcomes/variability of service, quality to funding – goal to just describe current state. According to the Blue, Inc. report, 16-20% amount of CMHC’s budget which goes towards those requirements under their certifications which they are not reimbursed for. (Uncompensadted care) Discuss institutional entitlement leads to funding w/o strings and regardless of outcomes of service (patient can’t walk away and take revenue stream) Lack of historical performance measures, or expectations for quality, efficiency, etc.

7. 7 CMHC per Capita SpendMedicaid Rehabilitation Option All these slides show variability –see note on next page!All these slides show variability –see note on next page!

8. 8 CMHC per Capita SpendMRO - Partial Hospitalization

9. 9 Percentage of State HAP Funds Used for MRO Match

10. 10 Federal Rule Changes Need better data here – what impact anticipated to be? Discuss details of each off this slide. IGT— Federal Savings $3.87 - 21 Billion over 5 years depending on source (HHS, CBO, Congress) State Impact Shortfall in CMHC funding MRO— Federal Savings $1.4 - 5.2Billion over 5 years depending on source (HHS, CBO, Congress) State Impact TCM— Federal Savings $1.28- 3.1 Billion over 5 years depending on source (CMS, CBO, Congress) State Impact Need better data here – what impact anticipated to be? Discuss details of each off this slide. IGT— Federal Savings $3.87 - 21 Billion over 5 years depending on source (HHS, CBO, Congress) State Impact Shortfall in CMHC funding MRO— Federal Savings $1.4 - 5.2Billion over 5 years depending on source (HHS, CBO, Congress) State Impact TCM— Federal Savings $1.28- 3.1 Billion over 5 years depending on source (CMS, CBO, Congress) State Impact

11. 11 Conclusions The current delivery system demonstrates unacceptable variability in terms of access, cost per person served, and quality. The current funding methodology is not sustainable. Need to pause a moment on this slide to assess if audience concursNeed to pause a moment on this slide to assess if audience concurs

12. 12 Drivers of Unsustainable Model Breadth of population served limits depth of services to SMI Inconsistent use of evidence-based practices Service delivery driven by funding Under-utilized Medicaid coverage & Over-leveraged Medicaid utilization Lack of delivery system accountability Fragmentation of mental health and other healthcare delivery systems High uninsured rate among adults with behavioral health needs We believe these primary drivers lead to the aforementioned conclusions of unacceptable variability and unsustainable funding. To move forward the solutions must address each of these primary drivers.We believe these primary drivers lead to the aforementioned conclusions of unacceptable variability and unsustainable funding. To move forward the solutions must address each of these primary drivers.

13. 13 Impact of Prioritization Breadth of Population Served Limits Depth of Services to SMI Note that 1997-2006 the number of those in HAP has doubled Total (MRO & HAP) funding per client has decreased by 18% since 97 Breadth of Population Served Limits Depth of Services to SMI Note that 1997-2006 the number of those in HAP has doubled Total (MRO & HAP) funding per client has decreased by 18% since 97

14. 14 CANS and ANSA Uniform functional assessment tools Identification of unique needs for each individual served Maps to Level of Care (LOC) Decision support tool to assist in delivering appropriate services to match patient’s needs Tool Administration Fidelity Note: talk about research and evaluation by independent consultants and ask for input from providers Our recommendations: Administered by behavioral health providers Regular audits to be conducted to ensure fidelity Note: talk about research and evaluation by independent consultants and ask for input from providers Our recommendations: Administered by behavioral health providers Regular audits to be conducted to ensure fidelity

15. 15 Assessment Tool: Levels of Care (LOC) ANSA is currently in pilot-phase and will go live July 1, 2008. Data is not yet available. CANS has been in place since July 1, 2007. Next step would be to focus on which services to include, prioritize to address clinical & social need ANSA is currently in pilot-phase and will go live July 1, 2008. Data is not yet available. CANS has been in place since July 1, 2007. Next step would be to focus on which services to include, prioritize to address clinical & social need

16. 16 CMHC per Capita SpendAssertive Community Treatment Inconsistent Use of EBPs ACT show less variability than other services. This is likely attributable to the fact that ACT is a well defined service which is only provided to a well defined portion of the SMI population.Inconsistent Use of EBPs ACT show less variability than other services. This is likely attributable to the fact that ACT is a well defined service which is only provided to a well defined portion of the SMI population.

17. 17 Current FSSA Coverage Vehicles for MH Services Under-utilized Medicaid coverage & Over-leveraged Medicaid utilization MEDICAID FAIL FIRST Discuss options of Medicaid disability, 1634 vs 209b, modernization process 1915(i) option, waiver consideration, otherUnder-utilized Medicaid coverage & Over-leveraged Medicaid utilization MEDICAID FAIL FIRST Discuss options of Medicaid disability, 1634 vs 209b, modernization process 1915(i) option, waiver consideration, other

18. 18 Medicaid Mental Health Spendby Category of Service and Age NEED NEW CLINIC DATA—NOT AVAILABLE AT THIS TIME. NEED NEW CLINIC DATA—NOT AVAILABLE AT THIS TIME.

19. 19 Utilization Management Potential Models Prior Auth. (PA) all services for all members PA select services for select diagnoses Service packages A priori Based on need Based on standardized assessment Considerations Cost of PA Delay in services Administrative burden Lack of quality/outcomes data Lack of Delivery System AccountabilityLack of Delivery System Accountability

20. 20 Proposed Service Packages EBPs like Supported Employment, IDDT, IMR, etc.  EBPs like Supported Employment, IDDT, IMR, etc. 

21. 21 Fragmentation of Delivery System Needs for successful HIE Link across networks and between mental health and physical health Protection of patient information Standardized data collection methods Standard methods accessing and reporting data BHMI survey—current use of EMR at CMHCsFragmentation of Delivery System Needs for successful HIE Link across networks and between mental health and physical health Protection of patient information Standardized data collection methods Standard methods accessing and reporting data BHMI survey—current use of EMR at CMHCs

22. 22 Principles of Transformation Promote a more recovery-oriented service delivery system Focus on outcomes and improved quality of life Maximize resources and assure accountability Improve access to basic healthcare for persons with SMI, SED, and/or CA Align funding strategies with service expectations Transition from institutional entitlement to individual enfranchisement

23. 23 Critical Assumptions The new service/funding system will be shaped by both DMHA and OMPP with input from stakeholders. The Transformation Model will drive the timeline, key initiatives, and feedback.

24. 24 Timeline Phase I Target Population Coverage Vehicles Uniform Assessment Tool Covered Services Utilization Management Integration Pilot/s Phase II Provider Community Expansion/Consolidation System-wide Integration