Harriet L. Hall, Ph.D., President and CEO Jefferson Center for Mental Health

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Amy Charles
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1 Harriet L. Hall, Ph.D., President and CEO Jefferson Center for Mental Health Medicaid expansion state State-run health insurance exchange Colorado Office of Behavioral Health renamed in 2010 to reflect integration of mental health and SUD, though providers still licensed and funded separately In Medicaid: Mental health is paid for through capitation via a carve out and managed by Behavioral Health Organizations (BHOs) under a 1915 (b) (3) Managed Care Waiver SUD treatment was paid for fee for service (FFS) until Jan, 2014 when expanded benefits were rolled into BHO contracts (but not a full benefit like mental health). Primary care is FFS No Health Homes for Persons with Chronic Conditions (2703 Medicaid waiver) 1

integration of mental health and SUD, though providers still licensed and funded separately In Medicaid: Mental health is paid for through capitation via a carve out and managed by

2 Behavioral health is carved out Department of Health Care Policy and Finance (HCPF) provides capitated contracts to 5 Behavioral Health Organizations (BHOs) BHOs assume risk and manage the care of all of the covered lives in their service area Community Mental Health Centers are paid monthly by the BHOs based on the number of covered lives in their service area and expected utilization of services or a negotiated fee for service. Physical health is paid for using fee for service billing Not managed care (Denver Health exception) Participation in Medicaid is voluntary for primary care practices The Accountable Care Collaborative (ACC) was developed by HCPF in May, 2011 with goals to transform the Medicaid program into a better system of integrated care for clients and to lower health care costs for the State of Colorado. 2

services or a negotiated fee for service.

3 As of Feb, % of all Medicaid recipients in Colorado are enrolled in the Accountable Care Collaborative Payment methodology: Care Coordination payments on top of traditional FFS. Failed attempt at shared savings. Advanced primary care practice can earn additional $.50 PMPM. ACC Payment Reform Initiative (1281 pilot) Key Performance Indicators: Reductions in emergency room visits Well-child checks Post-partum care 3

Failed attempt at shared savings. Advanced primary care practice can earn additional $.50 PMPM.

4 A partnership between Rocky Mountain Health Plans, the University of Colorado, Department of Family Medicine, and the Collaborative Family Health Association, SHAPE is testing a global budget model for integrated healthcare (medical, mental and behavioral) in six primary care practices in western Colorado. Main Objectives To determine if a global payment method will financially support and sustain behavioral health in primary care; To understand how different payment models will affect clinical models of integration and their related costs; and To test the real world application of a global payment methodology on primary care practices who have integrated behavioral health with the end goal to inform policy. Global Payments Risk adjusted prospective payment for defined period; Shared risk and accountability in budget, and quality targets between practices and payer; and Incentive opportunity for quality improvement in patient health outcomes. 4

Main Objectives To determine if a global payment method will financially support and sustain behavioral health in primary care; To understand how different payment models will affect clinical models

The overarching goal of Colorado SIM is to improve the health of Coloradans by providing access to integrated primary care and behavioral health services in coordinated community systems, with

5 The overarching goal of Colorado SIM is to improve the health of Coloradans by providing access to integrated primary care and behavioral health services in coordinated community systems, with value-based payment structures, for 80 percent of state residents by In December, Gov. Hickenlooper announced that Colorado will receive $65 million in SIM funding over 4 years 400 primary care practices and 4 CMHC based health homes Payors at the table, but no firm commitments 5

percent of state residents by 2019. In December, Gov.

6 Examples from Jefferson Center Solutions Now Jefferson Center does all FFS billing Practice provides referrals and scheduling assistance Physically located within primary care clinic May be available for consultation on a limited basis Provides traditional mental health therapy (40-60 minute visits) Client is given an intake and opened to Jefferson Center BHP charts in Jefferson Center s EHR gives PCP the progress notes and they scan into EHR Contract in place; both parties pay a portion of expenses for Behavioral Health Professionals Practice provides referrals and scheduling assistance, as well as warm hand-offs in real time Physically located within the pod Routinely provides consultation Provide short term counseling to clients who are having difficulty with medical compliance or control of chronic illness Provides screening, assessment, brief therapy, referral for longer term treatment BHP charts in MCPN s electronic health record 6

gives PCP the progress notes and they scan into EHR Contract in place; both parties pay a portion of expenses for Behavioral Health Professionals Practice provides referrals and scheduling

services Evidence based chronic disease management Collaborative care planning Advisory board with consumer

7 Level 5 integrated mental health, substance abuse, primary and preventive care Wellness services including peer wellness coach Care Coordination Labs done on-site Access to specialty care Benefits navigation and ancillary services Evidence based chronic disease management Collaborative care planning Advisory board with consumer representation Formal evaluation through Tri West Health Information Exchange Using Continuity of Care Documents (CCDs) 7

8 Fee For Service vs. value based payments Carve in vs. Carve out Covered diagnoses Limited options for reimbursement for care coordination activities (even more so for CMHCs) Over reliance on grant funds No reimbursement for provider to provider consultation or collaborative care planning Limited reimbursement for wellness and health coaching Shared Savings Downside Risk Fee for Service Pay for Performance Care Coordination Payments Bundled Payments Global Payments Increasing Accountability Collaboration Complexity Resistance and Potential Reward 8

grant funds No reimbursement for provider to provider consultation or collaborative care planning Limited reimbursement for wellness and

9 Bundled case rate for specific population Could include a particular diagnostic category, age group, or other determinant To include: Behavioral health payment carved out of capitation Primary care payment replacing ffs payment Shared savings agreement between payor, behavioral health provider, and primary care provider Hospitalization, pharmacy, and specialty care Partnership complications Negotiated profit share Control, culture, compensation, communication, etc. Requires large enough population to spread risk Requires good data Contract the devil is in the details 9

behavioral health provider, and primary care provider Hospitalization, pharmacy, and specialty care Partnership complications Negotiated profit

10 Harriet L. Hall Ph.D. President and CEO Jefferson Center for Mental Health 10

The Colorado Medicaid Accountable Care Collaborative Program

The Colorado Medicaid Accountable Care Collaborative Program September 12, 2011 Colorado Center on Law and Policy 789 Sherman St., Suite 300, Denver, CO 80203 303-573-5669 Colorado Medicaid s Accountable