DCF Behavioral Health Contracting and Reimbursement :

1. DCF Behavioral Health Contracting and Reimbursement: Current State Policy, Impact in Communities Lucia Maxwell, FADAA

2. National trends in health care • Consumer choice • Least restrictive (costly) service setting • Pre paid reimbursement • Provider networks • Quality benchmarks (data for consumers to compare provider performance) • Information Technology (EHR - electronic health record) Lucia Maxwell, FADAA

3. National trends in public policy - Chemical Dependency, Mental Health • Recovery emphasis; client‑centered service planning • Systems of care, not silo-ed agencies • Proven practices, performance measures • Continuous Quality Improvement (IT) • Pre-paid per capita and case rate reimbursement; Medicaid reform Lucia Maxwell, FADAA

4. Implications for the field: • Practice patterns changed – consumer friendly, shorter LOS. less residential & more Intensive Outpatient, focus on internal agency systems improvement • Real community wide planningaccess, client pathways, responsiveness to stakeholders • Managed care capacity: reserves, pre-authorizations, provider profiling, individual and aggregate client data • Inter-agency partnershipsfor services planning, and to share costly systems and financial risk Lucia Maxwell, FADAA

5. What part of managed care does DCF want? • Fewer contracts (nowover 480 statewide) • Assure best practices • Data to measure performance (provider profiling) • Flexible payment to match client to needed services (pre-paid) • Predictable budget, incentives for efficiency and access (pre paid) • Increase client access and # served(reduce waiting lists & unmet needs) Lucia Maxwell, FADAA

6. DCF Assumptions • Providers working together will create a system of coordinated services which better meet client needs. • Providers can collaborate to share the costs of staff, IT, & training. • Providers as partners can spread the financial risk of pre paid reimbursement. • Staff of a provider network will monitor services to assure best practices and improve outcomes, and will prepare reports for the state to review. • Both clients and community stakeholders can access a network easier than independent agencies. Lucia Maxwell, FADAA

7. History of DCF Managed Care Initiatives • CSAT report 2000: networks, care management • Commission on MH/ SA: need system changes in contracting, financing • SB 1258 (2001): quality/ best practices, data for planning, risk sharing/ control costs, flexibility to fit payment to service needs. PILOTS • SB 2404 (2003): DCF/ AHCA jointly develop all policy, budgets, procurement procedures, contracts and monitoring common service definitions, standards and accountability mechanisms • 2003: DCF can establish new data systems and fee for service, pre-paid capitation or pre-paid case rates by administrative rule. • HB 1843 (2004): Medicaid pre-paid expanded statewide • Late 2004: Single ME paper: DCF contract with Medicaid contractor • “System conversion” work groups 2005 – 2006: specifications for Managing Entity contracting Lucia Maxwell, FADAA

8. Most recent State policy actions • No new funds for Managing Entity infrastructure development (only agency contributions & direct service dollars) • DCF Secretary Hadi wants client centered planning for ME development • Community determination of ME structure: provider network, district office or lead agency as managing entity • DCF is planning for case rate reimbursement, beginning with methadone. Lucia Maxwell, FADAA

9. Florida Statues sayDCF may contract with: • A single managing entity or a provider network in each area or region • A “managing entity” is defined as: 1. A network of existing providers with an Administrative Services Organization that can function independently 2. An ASO that is independent of local provider agencies, or 3. An entity of state or local government. Lucia Maxwell, FADAA

10. At this time, DCF managed care policies preserve non-profit, community based systems of care and traditional providers Takenote: If this is not successful, the State could contract with for profit Managed Care Organizations (selective contracting, for profit providers, cost reduction objectives primary.) Lucia Maxwell, FADAA

11. What are the options for ME organization? • District office could retain the authority • A lead agency could be chosen: County government? A large community mental health center? • Prepaid mental health plan as SME • Provider network with a staff (ASO) Lucia Maxwell, FADAA

12. State Managing Entities • Northeast Florida Addictions Network – SA only • South Florida Provider Coalition (#11) - SA/MH • Southwest Florida Behavioral Health (#8) - SA/MH • Central Florida Behavioral Health Network (#5, #6, #14) - SA/ MH • Premier Services Network (district #7) – SA only • Lakeview as lead agency in district #1 contracts for DCF, Medicaid and CBC revenue – SA/MH. Lucia Maxwell, FADAA

13. Successful communities will have network leaders who • are wiling to enforce standards of care • represent ALL service recipient communities (racial/ ethnic minorities) • work well with local government for coordinated planning, financial support • attract local philanthropic support • are willing to change services and practice patterns to improve system of care. Lucia Maxwell, FADAA

14. Network challenges • Leaders who are “historical preservationists, ” slow to change practice patterns, can’t give up single agency focus, focus on competition over collaboration, lack client orientation   • Working together to build trust over time, overcome traditional rivalries, be willing to undergo peer review • Power in the network comes from performance, market position, leadership in the larger community, $ contribution to infrastructure costs. Lucia Maxwell, FADAA

15. Unresolved issues • Will competitive bidding be required: areas without networks? areas with established networks? • ME required functions and capacities: what are we willing to pay for? • Consumers and stakeholders on ME Board? • ME contracts: outcome or process driven? • Coordination with Medicaid and with MH • Linkages with HMOs, PMHPs, CBCs Lucia Maxwell, FADAA

16. In communities where agencies have formed networks/ MEs • Providers together accept responsibility for meeting performance objectives (DCF services) • DCF performance standards begin to shift to system wide objectives: e.g. reduce waiting lists; increase services to children • The State continues to transfer authority and money • Providers have assurances and can make long range plans. Lucia Maxwell, FADAA

17. Environmental conditions which will influence future policy • Continued strong support for MEs from DCF leadership. • Provider initiative to form networks and develop Managing Entity capacities. • DCF re-tooling: staff training, capacity to monitor outcome based & prepaid contracts. • Future status of Medicaid Prepaid Mental Health Plans. • Limitations of AHCA and DCF staff time and resources • Changes in State Administration: Governor’s office, DCF, AHCA Lucia Maxwell, FADAA

18. Medicaid Substance Abuse • Nowhere in the state is Medicaid substance abuse capitated today. • When Medicaid reform demos are concluded in 2008, sub abuse may be added to MC contracts. • Prepaid MH Plans are not eligible contractors under Medicaid reform, only Health Maintenance Organizations (HMOs) and hospital/ physician Provider Service Networks (PSNs) . . • HMOs and PSNs could subcontract sub abuse (and mental health) services to DCF Provider Networks and MEs. • DCF Managing Entities could negotiate higher rates by assuming some of the managed care functions (credentialing, QA/ QI, authorizations.) • Alternative policy for Medicaid sub abuse ($12 m statewide): AHCA contract with DCF to manage the care. Lucia Maxwell, FADAA