Florida Health. Prepaid Mental Health plan

Transcription

1 Florida Health Partners, Inc. Prepaid Mental Health plan

2 FHP Organizational Structure

3 Florida Health partners, Inc Public - Private Partnership ValueOptions National public sector experience Managed care systems Financial resources Risk contract models QM & Outcomes systems Technology and data management systems Reliable claims system National accreditation Behavioral Health Providers Local public sector experience Community commitment Relationships with local agencies, plan members, regulatory agencies, etc. Broad spectrum of services Multiple treatment sites National accreditation 3

4 Florida Health Partners Operating since 1996 in Medicaid Area 6 (Tampa area) 65K members VO and 5 community mental health centers Mental Health Care, Inc. Northside Mental Health Center Manatee Glens Corporation Peace River Center Winter Haven Hospital, Inc. Behavioral Health Division Associate providers Tampa General Hospital St. Joseph s Hospital Coastal Behavioral Health Care Lakeland Regional Medical Center 4

5 ValueOptions, Inc. Second largest BHO, largest in Public Sector Privately held corporation Ronald Dozoretz, MD Corporate Headquarters: Norfolk, VA 22 offices nationwide, 4,000 employees Manage care for 16 million persons, 4 million in Public Sector Organized by semi-autonomous divisions for focused services Emphasize shared system management with providers and alignment of incentives Florida Public Sector Division Office: Tampa 5

6 Participating 50% Partner Florida Behavioral Health, Inc. 5 RCC Members FHP Owner Roles 50/50 Ownership FHP Board 3 FBH Memebers 3 ValueOptions Members Managing 50% Partner ValueOptions Appoint Approve contracts Assure contract compliance representatives to FHP Board Provide technical assistance for any unresolved issue between FBH member and ValueOptions Provide a vehicle for member coordination, support, and resource sharing Assure provider and local community perspectives are addressed Approve FHP Budget Approve Network Members Approve Clinical Guidelines Approve FHP Rates Approve Clinical Quality Improvement Plan Represent FHP to State & Community Assure care meets FHP regulatory and professional standards for quality Provide system oversight for FHP Board Promote Best Practices Promote financial viability and risk management Obtain PLHSO Provide FHP President and addressed License Medical Director to manage partnership 6

7 TAMPA REGIONAL SERVICE CENTER REPORTING RELATIONSHIPS Robert H. More Public Sector Division - Chief Operating Officer/SCVP J. David Moore, M.D. John Dillon Medical Director Vice President Administrative Operations Robin Hamel, RNC Director, Clinical Quality Operations Doug Quintana Director, MIS Amy Rice Director, Outreach & Provider Services Russell Morgan Director, Finance Bernie Roy Office Manager Executive Office 7

8 Tampa Regional Service Center functions 24/7 Call Center Financial Management Quality & Outcomes UM & Medical Management Operations &U Underwriting Systems Eligibility Management Decision Support Clinical Standards & Contract Compliance Systems Protocols Monitoring Member & Provider Services PE&O Activities Special Population Protocols Data Management & Reporting Related Systems Coordination Network Risk Claims Management Management Processing 8

9 Overview: Medicaid Prepaid Mental Health Plan

10 Medicaid Prepaid Mental Health Plan (PMHP) Based on Freedom Of Choice Federal Waiver (1915b) First in 1996 Current waiver allows single or multiple behavioral health vendors HMO Or MediPass for physical health care 20 Capitation (PMPM) rates based on age and eligibility category (TANF, SSI, Foster Care, SOBRA) Based on 91% of projected fee-for-service expenditures Contracts by AHCA areas Required vendor must meet AHCA & DOI managed care financial requirements (PLHSO) 10

11 Medicaid Prepaid Mental Health Plan (PMHP) - continued Behavioral health covered services Inpatient Care Emergency Services Community Mental Health Services Targeted Case Management Exclusions Medicaid/Medicare Dual Eligibles Medications Institutional Care Residential Treatment Substance Abuse (temporary) Therapeutic Foster Care Transportation Replaces fee-for-service Medicaid 11

12 SB 2404 Changes Substance Abuse to be added by 2006 Expansion to all AHCA areas by June 30, 2006 AHCA must coordinate with ADM and assure clinical systems meet CBC and other special population needs Traditional community behavioral health providers and hospitals with psychiatric units must be offered network participation i Increased emphasis on choice of provider (organization) Single Vendor vs. HMOs and carve out being debated 12

13 PMHP Contractual and Operational Focus

14 PMHP Contractual and Operational Focus Overview Full Risk = provide all medically necessary services in the benefit plan and meet all admin requirements regardless of cost Contract duration: = 6 years Eligibility categories: TANF, SSI, Foster Care, and SOBRA in MediPass 14

15 PMHP Contractual and Operational Focus - continued PLHSO required - DOI requirements - financial viability focus Medical Necessity Based Service Covered disorder requires treatment Covered services are appropriate p for the disorder Services provided have been shown to be effective for disorder Services provided are not solely for the preference of an external party (family, other organization) 15

16 PMHP Contractual and Operational Focus - continued Access Standards No Wait Lists Emergency - Within Four (4) Hours Urgent - Within One (1) Business Day Routine - Within Seven (7) Days Follow-Up - Within Fourteen (14) Days Then Based on Treatment Plan Credentialed Network with Access, Capacity, and Required Specialties 16

17 PMHP Contractual and Operational Focus - Continued Quality of Care Monitoring Chart audits for appropriateness, timeliness, effectiveness, and coordination Access documentation Satisfaction audits Complaints and grievances Adverse incidents Pharmacy data for quality care and PCP coordination 17

18 PMHP Contractual and Operational Focus - Continued Care Coordination Child welfare programs Juvenile justice programs Juvenile assessment centers State hospital Jails and booking centers Primary care physicians Substance abuse providers Residential treatment programs School systems 18

19 PMHP Contractual and Operational Focus - Continued Consumer Empowerment Recovery and reintegration activities Self help groups Increased involvement in community activities 19

20 PMHP Contractual and Operational Focus - Continued Reporting Requirements Outcomes Utilization Monitoring activities Sub population specific data Case management Network capabilities Satisfaction Complaints and grievances Pharmacy QI activities and results Claims summary Financial audits and cost reports 20

21 PMHP Contractual and Operational Focus - Continued Outreach Members & providers Community organizations and agencies Primary care physicians Educational materials Community meetings and event participation Health and Resource Fairs Resource Guides Member Advisory Committee 21

22 Impact of PMHP on Providers

23 Impact of PMHP on Providers Contract involves risk May not use wait lists to manage demand Responsible for all covered diagnoses and services included in benefit plan Must provide all medically necessary services regardless of cost Emphasis changes from program capacity, volume and compliance to timeliness, outcomes and satisfaction Risk subcontracts support predictable & flexible funding 23

24 Impact of PMHP on Providers - Continued Clinical systems must refocus from maximizing volume to efficient delivery & desirable outcomes Must be able to identify and manage the 20/80 consumers Must be able to identify and manage outliers: services and consumers Consider FACT as part of the community array of services 24

25 Impact of PMHP on Providers - Continued Must be able to accurately encounter billed services and meet other reporting requirements Must be able to coordinate and integrate services with CBCs Case management must evolve to managed care approach FARS and CFARS outcomes (revised) reporting required 25

26 Impact of PMHP on Providers - Continued Must decide how to address SA disorders: Primary and Co-occurring Must meet geographic access for services and physicians Treatment must be truly individualized and produce positive outcomes Recovery philosophy and application required 26

27 Impact of PMHP on Providers - Continued Must demonstrate best practice implementation and evidence based care Pharmacy data must be used to improve medication therapy and PCP integration Systems must be HIPAA compliant System-wide CQI participation required 27

28 FHP: An Effective Public Private Partnership

29 FHP: An Effective Public Private Partnership Governance is balanced and reflects degree of risk assumed by each participant Governance system promotes consensus, accountability and timely decision making Financial incentives promote performance, efficiency, and quality care Utilizes the ValueOptions as a neutral manager and change agent 29

30 FHP: An Effective Public Private Partnership - continued FHP has achieved the following: Timely access To appropriate services In cost-effective settings That produce positive outcomes And plan member satisfaction By managing systems of care and outliers While partnering with providers And using advanced technology for efficient and effective operations. 30

31 ValueOptions Contacts Bob More, COO, Public Sector Division Phone: (813) John Dillon, VP, Administrative Operations Phone: (813) David Moore, M.D., Medical Director Phone: (813)