A Primer on Healthcare Reform: Key Concepts and Getting Ready – Next Steps

1. A Primer on Healthcare Reform: Key Concepts and Getting Ready – Next Steps Presented to the System Leadership Team July 9, 2010 Robin Kay, Ph.D. Chief Deputy Director

2. Healthcare Reform: Data that Sets the Stage • Less than 5% of Medicaid beneficiaries account for more than 50% of overall Medicaid costs (not just mental health) • 45% of beneficiaries have 3 or more chronic conditions • 49% of beneficiaries with disabilities have a psychiatric illness (Source: Center for Healthcare Strategies October 2009) County of Los Angeles – Department of Mental Health A Primer on Healthcare Reform

3. Healthcare Reform: Four Key Components • Insurance Reform • Coverage Expansion • Delivery System Redesign • Payment Reform County of Los Angeles – Department of Mental Health A Primer on Healthcare Reform

4. Healthcare Reform: Four Key Components • Delivery System Redesign: Changes in Service Delivery Models • Concept of Medical Home/Behavioral Healthcare Home • 4-quadrant model from The National Council for Community Behavioral Healthcare County of Los Angeles – Department of Mental Health A Primer on Healthcare Reform

5. Healthcare Reform: Four Key Components County of Los Angeles – Department of Mental Health A Primer on Healthcare Reform

6. Healthcare Reform: Four Key Components • Delivery System Redesign: Changes in Service Delivery Models (Con’t) • Possible Structural Alternatives • Fully Integrated Programs • One provider with ability to address all 4 quadrants through several team approaches • Formal Partnerships between Primary Care and Behavioral Health Providers • Two organizations with operational agreement County of Los Angeles – Department of Mental Health A Primer on Healthcare Reform

7. Healthcare Reform: Four Key Components • Possible Structural Alternatives (Con’t) • Behavioral Health Providers with Established Links to Many Primary Care Programs • Current arrangement in LAC-DMH • National Council Recommended Mandatory Elements: • Regular screening at time of psychiatric visits • Identify primary care provider for all clients • Explicit methods for communication and care coordination with primary care providers • Provide education and linkage to self-management assistance and support groups County of Los Angeles – Department of Mental Health A Primer on Healthcare Reform

8. Healthcare Reform: Getting Ready • Next Steps for LAC-DMH • Educating ourselves • Developing a clear model for integrating behavioral healthcare prior to primary care integration • Identifying existing models/programs that work • Project-50 • AB2034/FSP/Adult Hospital Linkage Project • Santa Monica Dual Diagnosis Project • Others County of Los Angeles – Department of Mental Health A Primer on Healthcare Reform

9. Healthcare Reform: Getting Ready • Next Steps for LAC-DMH (Con’t) • Implementing new Projects with an eye towards healthcare reform • Innovations • PEI directly operated programs’ collaboration with DHS • Co-location of FQHCs in outpatient clinics County of Los Angeles – Department of Mental Health A Primer on Healthcare Reform

10. The 1115 Waiver and CEED A Primer on What Lies Ahead for Mental Health October 13, 2010 Robin Kay, Ph.D., Chief Deputy Director and Roderick Shaner, M.D., Medical Director County of Los Angeles – Department of Mental Health

11. The 1115 Waiver and CEED What is an 1115 Waiver? • Plan for a state’s delivery of services to Medicaid (Medi-Cal) and Medicare beneficiaries • Requires approval by the federal Centers for Medicare and Medicaid Services (CMS) • Basis for CMS tracking and auditing of the services provided within a state • Services provided under a waiver must be “revenue neutral” County of Los Angeles – Department of Mental Health A Primer on Healthcare Reform

12. The 1115 Waiver and CEED • What is a CEED? • CEED = Coverage Expansion and Enrollment Demonstration Project • CMS Funds are saved through efficient operation of Medi-Cal under the waiver • Saved funds used as 50% match for defined services to a priority population of uninsured individuals in participating counties • CEED has defined minimum managed benefits package of health and mental health services County of Los Angeles – Department of Mental Health A Primer on Healthcare Reform

13. The 1115 Waiver and CEED Planning for the “New” Waiver • California DHCS implemented a stakeholder process including outpatient providers, hospitals and consumers • Underlying principle: An integrated approach to physical health and mental health care in the community as well as in a hospital setting County of Los Angeles – Department of Mental Health A Primer on Healthcare Reform

14. The 1115 Waiver and CEED Key Elements of the “New” Waiver • Priority Population • Funding, Revenue and Reimbursement • Service Delivery Models • Coverage Expansion and Enrollment Demonstration (CEED) projects • The Mental Health Benefit - A Three Tiered Approach • Beneficiary Enrollment County of Los Angeles – Department of Mental Health A Primer on Healthcare Reform

15. The 1115 Waiver and CEED • CEED Priority Population • Childless adults (18 years and older) • Below 133% of Federal Poverty Level (FPL) • Income as the key criteria – not serious and persistent mental illness • Excludes individuals who are undocumented, non-legal residents County of Los Angeles – Department of Mental Health A Primer on Healthcare Reform

16. The 1115 Waiver and CEED • CEED Service Delivery Models • Primary medical home • Primary behavioral healthcare home • Integrated care • Care coordination County of Los Angeles – Department of Mental Health A Primer on Healthcare Reform

17. The 1115 Waiver and CEED • The Challenges Ahead of Us • Developing relationships among DHS CHCs, PPPs, specialty mental health clinics – both directly operated and contracted • Developing a case rate at the end of Year 1 • Managing care to adequately treat clients while minimizing risk • Identifying outcome measures that will serve as a basis for healthcare reform County of Los Angeles – Department of Mental Health A Primer on Healthcare Reform