Demystifying Managed Care

Transcription

1 Demystifying Managed Care BEST Meeting October 23-24, 2013

2 Agenda Community Care introduction About Community Care Goals and objectives MCO critical functions Innovation highlights Current Planning in New York Clinical Home Models for Adults and Children 2

3 Role of States in Monitoring Performance Monitor MCO performance in meeting CMS program standards and requirements: Monitoring population management and special needs; access and availability of services Ongoing reporting requirements Quality management oversight Annual review process External quality monitoring 3

4 Role of MCO s Provide general managed care operations on behalf of the state Provide clinical oversight and leadership of care management activities Ensure quality care to those with complex needs Enhance the efficacy of the clinical service system 4

5 Overview of Community Care

6 About Community Care Incorporated in 1996 primarily to support Pennsylvania Part of the UPMC Insurance Services Division 501(c)(3) nonprofit behavioral health managed care organization Licensed as risk bearing PPO Implemented HealthChoices in 39 counties (as of July 1, 2013) in Pennsylvania beginning in 1999 Experience with full-risk, shared-risk, and Administrative Services Only (ASO) contracts CMI in NYC: BHO in the 16 County Hudson River Region: present 6

7 Community Care in New York Implemented a Care Monitoring Initiative in New York City (2009) Awarded 16 county Hudson River Region in Behavioral Health Organization (BHO) Initiative (2012) New York Office of Mental Health (OMH) New York State Office of Alcoholism and Substance Abuse Services (OASAS) 7

8 Accreditation/Commendations NCQA: full accreditation status for Medicaid, Medicare, Commercial & Disease Management (perfect scores) Moffic Award: American Association of Community Psychiatrists ESPRIT Award: Mental Health Association of Allegheny County Corporate Award NAAR Appreciation Award: National Alliance for Autism Research Appreciation Award Certificate of Recognition for contributions to Western Pennsylvania Autism Community 8

9 Membership Trend FY 2003 FY 2004 FY 2005 FY 2006 FY , , , , ,938 FY 2008 FY 2009 FY 2010 FY 2011 FY ,043,125 1,097,645 1,297,458 1,377,419 1,528,003 9

10 Membership Trend Membership Trend FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY

11 Community Care HealthChoices Regions Erie Crawford Mercer Lawrence Butler Beaver Allegheny Washington Greene Venango Armstrong Westmoreland Fayette Clarion Warren Forest Jefferson Indiana Somerset Cambria McKean Elk Clearfield Cameron Bedford Fulton Potter Clinton Centre Franklin Tioga Mifflin Lycoming Cumberland Adams Bradford Luzerne Columbia Montour York Sullivan Juniata Blair Perry Dauphin Lebanon Huntingdon Lancaster Susquehanna Wyoming Lackawanna Union Carbon Northumberland Snyder Schuylkill Berks Chester Wayne Monroe Pike Northampton Lehigh Bucks Montgomery Delaware Philadelphia Southwest Region Lehigh-Capital Region Southeast Region Northeast Region North Central Region County Option North Central Region County Option Pending Contract Pending Contract Community Care Office North Central Region State Option 11

12 Critical Functions of Managed Care Member Education & Outreach Community Relations Customer Services Care Management Utilization Management Quality Management Outcomes Management Program Development Network Management Service Access Credentialing Contracting Training Claims Processing IT Finance 12

13 Member Education & Outreach Member education Staff resources to ensure participation in community outreach efforts Educational resources for members: Member newsletter Service fact sheets Prevention materials 13

14 Member Orientation A member handbook is required and may be mailed or online and available to all eligible members: Covered services How to get help Rights and responsibilities Complaints and grievances Satisfaction measures Important contact information 14

15 Community Relations Provides education, outreach, and information to individuals and families about mental health and substance use disorder services available through the MCO 15

16 Customer Services First-line telephonic response to members, families, providers, and other stakeholders Serves as initial point of contact for members Assists members in linking to community resources Assists members by checking eligibility Answers any questions a caller may have Ensures member safety during the call 16

17 Care Management Team of licensed and specialty clinicians: Collect and review clinical information Assess medical necessity; authorize services Consult with physicians as needed Ensure coordination and continuity of care Promote the full participation of the member and family in treatment plan development Assess provider adherence to performance standards and best practices 17

18 Utilization Management At the member level, care managers work to ensure that members receive: The right service In the right amount or intensity For the right length of time In aggregate, clinical/quality leadership team review utilization trends for each level of care to determine appropriate interventions 18

19 Medical Necessity Criteria (MNC) MNC used to authorize care consistently MNC correspond to level and intensity of service MNC consider needs related to symptoms and diagnosis MNC maintain reliability and promote consistent decision-making 19

20 As an example: Behavioral Health MNC Community Care uses: Appendix T for child/adolescent and adult mental health criteria Pennsylvania Client Placement Criteria (PCPC) for adults for drug and alcohol placement. American Society for Addictive Medicine for child/adolescent alcohol and other drug criteria Internally developed MNC for specific levels of care (approved by DPW) 20

21 Network Management MCO contracts with providers to ensure members have adequate and accessible choice of providers All service rates are either set by the state or negotiated with providers individually depending upon state mandates 21

22 Quality Management Creates a reliable framework to measure and analyze performance over time while implementing real time interventions Measures performance against the community s best practices and industry standards Contributes relevant and valid information to every department to design effective interventions Improves outcomes by using empirically-based data Values member, provider, and stakeholder analysis 22

23 Provider Trainings Promotes quality of services rendered by network providers Seek stakeholder input to determine trainings to be offered Recent trainings include: Motivational interviewing D&A confidentiality Family systems theory 23

24 Provider Claims Processing Quality standards of claims payment usually set by the state e.g., x% clean claims paid within 30 days Online claims submission and status capability; includes direct data entry for providers without clearinghouses Claims training for providers 24

25 Information Technology Use of state approved software to document clinical information, authorizations, and claims data A comprehensive array of tools and reports should be available to effectively manage care and ensure timely and accurate communication with providers: Supports care management, credentialing, and network management functions Ensures effective quality improvement compliance monitoring activities Supports outcomes activities 25

26 Information Technology Continued Sophisticated analytic capability supported by stateof-the art data warehouse environment Decision support infrastructure supported by SAS Skilled analysts, statisticians, and developers create interactive reports Reporting tools customized for different user types Operations, compliance, regulatory, and clinically focused reporting 26

27 Commitment to Fiscal Responsibility Programmatic best practices implementation Adjust categories of service spending: Transition of services spending from institution/residence to community-based programs Efforts to improve cost effectiveness of community based programs 27

28 NYS Medicaid Behavioral Health Transformation Implementation Timeline SEPTEMBER BEHAVIORAL HEALTH DATABOOK (HARP & NON- HARP SPEND POPULATION) FEBRUARY POST FINAL RFQ WITH PENDING RATES FEBRUARY - APRIL RFQ TA CONFERENCES ANTICIPATED CMS APPROVAL OF 1115 WAIVER JANUARY IMPLEMENTATION OF BEHAVIORAL HEALTH ADULTS IN NYC (HARP & NON- HARP) OCTOBER DISTRIBUTE DRAFT RFI FOR COMMENTS MAY NYC PLAN SUBMISSION OF RFQ* JANUARY NOVEMBER POST HARP & NON-HARP RATE RANGES DECEMBER 1115 WAIVER SUBMISSION TO CMS MAY - AUGUST NYC PLAN DESIGNATIONS SEPTEMBER - NOVEMBER NYC PLAN READINESS REVIEWS JULY IMPLEMENTATON OF BEHAVIORAL HEALTH ADULTS IN REST-OF- STATE (HARP & NON- HARP) IMPLEMENTATION OF BEHAVIORAL HEALTH CHILDREN STATEWIDE

29 Initial HARP Eligible Population Mental Health Minimum Qualifications Medicaid Enrolled Initially, over 20 years of age as of 2011 (Qualifying services use prior to 21 st birthday is considered in qualification.) Could add individual based on functional assessment and diagnosis. e.g., first episode psychosis Non Medicare enrolled ( dual enrollee ) in the period Not eligible for OPDWDD managed care SMI diagnosis

30 Initial HARP Eligible Population Mental Health Other Criteria for Eligibility SSI or SSI/MA only and at least one organized mental Health Medicaid fee- for-service or Medicaid managed care service in 2011 SSI individuals who did not met the qualifications and non-ssi individuals who met the Minimum HARP Qualifications if they met one following qualifications: Received three or more claims for ACT, TCM, PROS, or PMHP services in any of the years Received more than 30 days of psych inpatient services in any of the last 3 years Had three or more psychiatric inpatient admissions in the three years 2009 through 2011 with at least one admission in 2011 Were discharged from an OMH PC after an inpatient stay greater then 60 days in last year Had a current or expired AOT ( Assisted Outpatient treatment ) order in Were discharged from NYS Department of Corrections with a history of inpatient or outpatient treatment through OMH s Central NY Psych Center in Were residents in OMH funded Housing for persons with serious mental illness in any of the years

31 HARP Eligible Population Substance Use 2 or more detoxification admissions (inpatient/outpatient) within 12 months (CY 2011) 1 inpatient rehabilitation within 12 months (CY 2011) 2 or more inpatient hospital admissions with primary substance use diagnosis or SUD related DRG and secondary substance use diagnosis within 12 months (CY2011) 2 or more emergency department visits with primary substance use diagnosis or primary non-substance use/related secondary substance use diagnosis within 12 months (CY 2011)

32 CY 2011 Medicaid Spend HARP/Non-HARP Populations

33 CY 2011 Top 20 Health Plans HARP/Non-HARP

34 Top 20 Defined Diagnosis HARP and Non HARP

35 GNYHA 35 Qualified BH Plan vs. HARP Plan Qualified to Manage Health And Recovery Plan Behavioral Health HARP Medicaid Eligible Benefit includes all covered Services Organized as Benefit within MMC Management coordinated with physical health benefit management Performance metrics specific to BH Eligible based on utilization pattern or functional impairment Benefits include all current PLUS 1915i-like Services Benefit Management built around expectations of higher need HARP patients Performance metrics specific to 1915i, and higher need population Managed Care Policy ad Planning Meeting slides presented by Bob Myers NYS OMH

36 GNYHA i-like services in the HARP Proposed Menu of 1915i-like Home and Community Based Services Psychosocial rehabilitation Community Psychiatric support and treatment (CPST) Residential Supports/Supported Housing Crisis Intervention Peer Supports Habilitation Respite/Crisis Respite Case Management Supported employment Education support Services Self-Directed services Non-Medical Transportation Training and Counseling for unpaid caregivers Family support and Training Managed Care Policy ad Planning Meeting slides presented by Bob Myers NYS OMH

37 New York Behavioral Health Benefit Package* Behavioral Health State Plan Services (for Adults) Inpatient SUD and MH Clinic SUD and MH PROS IPRT ACT CDT Partial Hospitalization CPEP TCM Opioid Treatment Outpatient Chemical Dependence rehabilitation Rehabilitation supports for community Residences Managed Care Policy ad Planning Meeting slides presented by Bob Myers NYS OMH

38 Draft Network requirements Contract with any OMH, OASAS provider serving at least 4 of their members in any of their counties (under review to tailor by program type) Contract with State operated OMH providers as Essential Community Providers Allow members to have a choice of at least 2 providers of each BH specialty service Continue to pay government rates for ambulatory services currently in place for 24 months Comply with all mandatory network requirements for 24 months from contract implementation Managed Care Policy ad Planning Meeting slides presented by Bob Myers NYS OMH

39 Improving Quality of Behavioral Health Prescribing Practices

40 Pharmacy Quality Improvement Program Includes psychiatrists, pharmacists, and data analysts Works closely with the Research, Evaluation, and Outcomes Department promoting health and well-being of members and improving physician prescribing behaviors Identifies outlier prescribing patterns and develops interventions to address the outliers Identifies unusual prescribing patterns that do not meet best practice standards and develops interventions to address them Monitors cost trends of behavioral health medications and assesses opportunities to improve cost effectiveness 40

41 Pharmacy Quality Improvement Program Continued Focuses on behavioral health issues, patient safety, and barriers to treatment Collaborates with physical health MCOs, prescribing physicians, and other stakeholders Pharmacy data for high-risk members available to care management staff coordinating care and supporting medication adherence Shares results of pharmacy-related activities with prescribers and other stakeholder groups Supports behavioral health and primary care practitioners in efforts to improve treatment with psychotropic medications 41

42 Information Line for Practitioners Primary care physicians and other health care practitioners can call with questions about diagnostic criteria and psychiatric medications Community Care psychiatrists and pharmacists are available 24 hours a day, seven days a week Answer questions about Community Care members related to medication effects, side effects, diagnostic criteria, and treatment resources 42

43 Clinical Homes for Adults and Children

44 Clinical Home Model for Adults Focused on coordination and integration of behavioral and physical health services for adults with serious mental illness Model includes: Placement of a nurse in case management units focused on physical health and wellness Training of case managers and peers as health navigators Self management models for activities such as smoking, weight management, and diabetes Initial implementation in four agencies in North Central region 44

45 PCORI Grant Recipient Project titled, Optimizing Behavioral Health Homes by Focusing On Outcomes That Matter Most for Adults with Serious Mental Illness $1.7 million dollar three year grant from the Patient- Centered Outcomes Research Institute (PCORI) to expand and evaluate the adult clinical home model Focus on individual and provider directed interventions to address wellness and physical health concerns Builds on prior work in North Central region Includes eight North Central agencies and three Chester County agencies 45

46 Children s Clinical Home Key Concepts Accountable clinical home Families are key stakeholders Structured training and implementation Evaluation and outcomes: Domains of functioning within child and family Academic performance Continued analysis of financial viability 46

47 Learning Collaborative Components Ecological structural family principles and intervention tools Resiliency and trauma-informed care principles and intervention tools Comprehensive biopsychosocial evaluation principles and application 47

48 Learning Collaborative Components Continued Positive Behavior Support (PBS) principles and intervention tools: In collaboration with Lucille Eber, PhD National Demonstration Project sites in two Pennsylvania school districts Combining children s clinical homes with PBS Co-occurring mental health and substance abuse principles and intervention strategies Very positive increase in engagement of children and families 48

49 Children s Clinical Homes Southwest School-Based Counties North Central School-Based Counties Northeast School-Based Counties Community Care Office Pike County Allegheny Clearfield Lackawanna Luzerne Northumberland Schuylkill Snyder Susquehanna Warren Wyoming School District Pittsburgh Public School District Clearfield Area School District DuBois Area School District Scranton School District Greater Nanticoke Area School District Hazelton Area School District Pittston Area School District Wilkes-Barre Area School District Wyoming Valley West School District Mount Carmel Area School District Minersville Area School District Pottsville Area School District Midd-West Area School District Selinsgrove Area School District Montrose Area School District Warren County School District Tunkhannock Area School District 49

50 Summary Responsive and accountable partner State-of-the-art information technology used to further the aims of the program Fiscally accountable: good steward of public resources Commitment to collaboration with human services, providers, members, and cross-systems coordination Innovative, clinically competent, and recovery focused Specialized care management for high-risk/high-need individuals, including coordination of care with community-based services Strong leadership team with extensive experience in the public sector 50