DCF System Conversion and Medicaid Managed Care: The impact on provider contracting and reimbursement.

1. DCF System Conversion and Medicaid Managed Care:The impact on provider contracting and reimbursement. Lucia Maxwell

2. DCF plans “system conversion”within two years • A managing entity will be selected by competitive bid for each district or region. • DCF will contract for SA and MH services with the Managing Entity rather than directly with providers. • The role of district office staff will change to that of “Purchaser.” • Parts of the DCF data system may be outsourced. • NO changes in local match: amt, sources, ratio Lucia Maxwell

3. What are DCF’s goals for the redesign? • Recovery oriented services, individualized treatment • Customer driven services • Systems of care, not “silo-ed” agencies • Assure best practices • Quality improvement • More flexible funding • Reliable data system • Preserve local $ contributions. Lucia Maxwell

4. What is a Managing Entity? • As defined in Florida Statutes: 1. A network of existing providers with an Administrative Services Organization(ASO) 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

5. What is a Managing Entity? In practice: • A group of providers establish a new corporation which will contract with the State. Providers become subcontractors. • The new corporation hires staff (contracting, finance, IS, monitoring, QA/QI, technical asst., outreach?) to develop protocols and procedures which build separate services into a system of care. • Capacities are built slowly over time. As trust develops, the dialogue among providers moves from resource allocation to improving access, responsiveness and quality. • CQI focuses on system goals, not agency goals (e.g. reduce days to service, improve placement and retention.) Lucia Maxwell

6. What will be the new role of district office staff? • Negotiating and monitoring a single contract for a services system. • Setting CQI measurable system goals for the Managing Entity to achieve (increase women’s services, decrease waiting lists, improve workforce development activities, increase detox capacity.) • Enhanced focus on community planning. • Build systems for determining stakeholder satisfaction with ME operations. • Develop mechanisms to ensure that services design and service delivery are consumer driven. Lucia Maxwell

7. Managing Entities are forming in many districts. • 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) • Northeast Florida Addictions Network(#4, #12, possible North Florida expansion?) • Lakeview as lead agency in district #1 contracts for DCF, Medicaid and CBC revenue – SA/MH. Lucia Maxwell

8. Implicit assumptions in DCF redesign. • District offices do not have the resources to take on these tasks. • The system is provider driven, so providers must take responsibility to build systems of care. • Managing Entity administration will be financed with a percentage of services dollars (likely 4% – 8%.) • Slow conversion from unit cost contracting to prepaid financing. Capitation unlikely, possibly case rates. • Not an insurance model, but better definition of eligibility for DCF services (by income, diagnostics.) • DCF goal is cost efficiency not cost containment. • MCO partnerships are not necessary in most areas. Lucia Maxwell

9. Unresolved issues • Degree of local determination: e.g. ME structure, single point of access, consumer advisory bodies • Governance requirements (e.g. Board composition) • ME contracts: outcome or process driven? • How to realize the goal of “braiding” Medicaid and DCF funding. • How DCF Managing Entities will coordinate care with HMOs, PMHPs, the CBC specialty network • Role of Managing Entities in contracting for Medicaid, JJ, Corrections funding Lucia Maxwell

10. Environmental conditions which will influence the initiative. • Continued strong support from current 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. • Mental health provider focus. Lucia Maxwell

11. Medicaid managed care 2005 – 2008? • Prepaid Mental Health Plans for Medipass clients selected for areas 1, 5, 6, 7 and under review for 2,3, and 4; AHCA will bid remainder by July, 2006 except possibly Dade County.) • Two PMHPs are partnerships between Value Options and area Community Mental Health Centers; Lakeview in district one. • Medicaid HMOs adding mental health after AHCA approves their network of providers; most direct contracting as opposed to behavioral MCO subcontract. • Medicaid substance abuse is likely to be added to these plans in 2006; some possibility that Medicaid could contract for sub abuse with DCF managing entities. • BHOS, SIPP waiver, foster group care exempt. Lucia Maxwell

12. Community Based Care Medicaid Specialty Network • RFP announced to select a lead community based care agency to contract for all Medicaid mental health services for HomeSafeNet children. • Sub abuse services are not included now. • The CBCs have formed a statewide organization and selected a Managed Care partner to bid on the contract. • The statewide contractor will subcontract for all services with local CBCs. • Local CBCs may deliver the services or contract with mental health service agencies. Lucia Maxwell

13. Evaluation of System Changes: • SA/MH Corporation will establish criteria and baseline data to measure impact of system changes, for reports to Legislature (sunsets October, 2006 if not reauthorized) • By December 31st, FMHI evaluation of pilots: recommendations and a timetable, milestones, and date certain for implementation of successful strategies statewide. Lucia Maxwell

14. Medicaid reform • Medipass and Prepaid Mental Health Plans are not mentioned in the reform law (SB 838) • The law says Medicaid will contract only with plans or networks which provide physical, behavioral and pharmacy services to their members. • AHCA’s 1115 waiver application to the feds (CMS) will be posted on the web for review within the month (Legislative review but not approval.) • Medicaid reform demos begin 2006 - 2007 in Broward and Duval; expansion to other counties is contingent on Legislative approval. • Changes defined benefit to defined contribution. Lucia Maxwell

15. Provider Sponsored Networksand Medicaid reform • Networks or their Managing Entities may contract with the Health Maintenance Organizations (HMOs) and Provider Service Networks (PSNs) proposed under Medicaid reform, for the community behavioral health services to be offered in plans. • Managing Entities can negotiate higher rates by assuming some of the managed care functions (credentialing, QA/ QI, authorizations.) Lucia Maxwell

16. Medicaid Substance Abuse • Nowhere in the state are Medicaid substance abuse services capitated. • Medicaid payments for substance abuse statewide are less than $15 million, 1/3 to ½ to hospitals. • Three new Medicaid codes authorized for counties willing to use local dollars as match: community detox, intervention, aftercare. No state GR. • Services financed with local dollars will never be contracted to Managed Care Organizations. • Contact your county staff about participation. More info: lomax@nettally.com Lucia Maxwell

17. What options do providers have? • Build or join a Provider Sponsored Network in your district or region (owner.) • Decline to participate in Managing Entity governance, but seek to contract with the Managing Entity in your area. (subcontractor.) • Negotiate a partnership with another agency which owns or contracts with a Managing Entity (merger.) • Contract with the MCO which receives the DCF Managing Entity contract for your area, if no community based ME is formed by local providers. Lucia Maxwell