Detailed Matrix of Select State Behavioral Health Systems

Transcription

1 Detailed Matrix f Select State Behaviral Health Systems The fllwing matrix utlines key aspects f 7 state behaviral Health mdels. It is rganized accrding t whether a state has a carve-in mdel, carve-ut mdel r is develping a ppulatin carve-ut mdel. Carve In States Gegraphic Area Scpe f Services Financial Mdel Perfrmance Measures Gals/Challenges KY 1 Three statewide Risk Based Cntract. Require NCQA accreditatin. MCOs (effective as Capitated payments, f Octber 2011). CDPS used t risk adjust MCOs crdinate all PH, BH, pharmacy, visin and dental (can subcntract). Members in nursing hmes and waivers will nt transitin t managed care. rates. Administrative csts cannt exceed 10% f the ttal managed care cntract cst. BH dllars are nt prtected Reprt annually n HEDIS measures; cntractr and department will select a subset f HEDIS reprted measures n which department will evaluate perfrmance and determine whether cntractr is required t implement a perfrmance imprvement initiative. Cnduct CAHPS survey. Mnitr and evaluate n an nging basis thrugh QA/PI and integrate BH indicatrs int its QA/PI prgram. Required t d perfrmance imprvement prjects (1 PH, 1BH). Required t reprt n trends in utilizatin, e.g.: Inpatient hspital admissins and days/ thusand member mnths Outpatient hspital visits per thusand member mnths % ER visits resulting in admissins As nted in the cntract, state is cncerned regarding use f evidence based practices fr behaviral health. Primary fcus will be n further develpment/ expansin f supprted husing, supprted emplyment, develpment f peer supprt and recvery mdels f care. 1 Infrmatin btained frm Kentucky Medicaid managed care cntract (Kentucky Spirit Health Plan), effective Octber 1, 2011, available at: Supprted by a grant frm the Rbert Wd Jhnsn Fundatin s State Health Refrm Assistance Netwrk. 1

2 Ambulatry surgery/ prcedures per thusand member mnths Hspital readmissins per thusand member mnths Average visit per prvider by majr type Mental hspital admits per thusand Prescriptins dispensed by majr drug class per thusand member mnths Cntractr must require prviders t fllw up after hspitalizatin fr behaviral health : Outpatient treatment must ccur within 14 days f day f discharge; Behaviral health prviders must cntact members wh missed appintments within 24 hurs t reschedule TN 2 Reginal MCOs. MCOs cver and integrate Full risk cntract. Required t d tw clinical TN mved t a carve-in PH, BH and LTC benefits fr all beneficiaries MCOs can subcntract, but stringent prvisins perfrmance imprvement prjects (1 in area f BH). mdel t avid MCO/BHO disputes regarding wh statewide. BH benefits included in cntract Require NCQA accreditatin. was respnsible fr a given include: regarding c-lcatin f Reprt n HEDIS measures claim. Psychiatric inpatient. staff and key persnnel at designated by NCQA as relevant t Carve-in mdel allwed 24-hur psychiatric the administrative level. Medicaid, CAHPS surveys. fr rganic develpment residential treatment. Capitatin rate fr each Prvide specialized service reprts: f integrated clinical Outpatient mental enrllee based n rate psychiatric hspital readmissin, mdels at a lcal level. health. categry, health plan risk pst discharge service reprt, Carve-in mdel requires 2 Infrmatin btained frm direct cmmunicatin with state fficials and Tennessee Medicaid (TENNCARE) managed care cntract, updated January 1, 2012, available at: Supprted by a grant frm the Rbert Wd Jhnsn Fundatin s State Health Refrm Assistance Netwrk. 2

3 Inpatient, residential and utpatient assessment scres, health status based n ACG case behaviral health crisis respnse reprt. substance abuse mix system BH HEDIS Measures used t benefits. MCOs all include BH determine pay fr perfrmance: Mental health case management. cnditins in risk stratificatin. Antidepressant medicatin management Psychiatric rehab. T ensure cntractr cmpliance with all Fllw-up care fr children prescribed ADHD BH crisis. requirements in cntract, medicatin there is a 10% withhld f Fllw-up after mnthly capitatin payment fr the first 6 mnths fllwing start date f peratin, and fr a 6 mnth perid fllwing receipt f a hspitalizatin fr mental illness 23 perfrmance standards with assciated liquidated damage fr failure t meet standards. BH related measures include: ntice f deficiency. If there are n deficiencies fr a 6 mnth perid, withhld is reduced t 5% f mnthly cap payment. Once reduced t 5%, will be further reduced t 2.5% if there are n deficiencies in a 6 mnth perid. Length f time between psychiatric hspital discharge and first mental health service that qualifies as pst-discharge (must nt exceed 7 days) Nt mre than 10% f members discharged frm inpatient/residential facility (psychiatric hspital) TENNCARE will make pay fr perfrmance quality incentive payments t the cntractr. Cntractr is eligible fr $.03 PMPM fr significant imprvement (defined using NCQA s minimum effect size change methdlgy) n PH readmitted within 7 days Nt mre than 15% f members discharged frm inpatient/residential facility (psychiatric hspital) readmitted within 30 days clse cllabratin acrss Medicaid/MH agencies. Supprted by a grant frm the Rbert Wd Jhnsn Fundatin s State Health Refrm Assistance Netwrk. 3

4 Carve Out States Gegraphic Area Scpe f Services Financial Mdel Perfrmance Measures Gals/Challenges HEDIS measures and BH HEDIS measures. See Perfrmance Measures clumn fr specific measures. BH dllars are nt CT 3 Statewide ASO fr Medicaid FFS ppulatin. Respnsible fr clinical-, utilizatin-, ICM-, quality- and data management. Required t enhance cmmunicatin and crdinatin within the BH system, assess netwrk adequacy and imprve verall service delivery. Cre clinical verseen by ASO: Intermediate inpatient psychiatric care Acute psychiatric hspitalizatin Partial hspitalizatin Intensive utpatient Outpatient Medicatin evaluatin/ management Substance abuse/ prtected Department f Scial Services (DSS) respnsible fr claims payments. Prfit (calculated as 7.5% f ttal administrative cntract csts) withheld and paid nly t the extent that the cntractr meets perfrmance targets. 7.5% f each quarterly payment withheld, paid in whle r in part based n success in meeting perfrmance targets (each has a separate value). Perfrmance targets tied t bjectives such as: Access Quality Overall child and adult cmmunity service t inpatient rati Overall expenditures. Infrmatin regarding specific perfrmance targets frthcming. In additin, specific perfrmance standards set by department. Failure t meet perfrmance standards will result in sanctins fr each ccurrence. Payment will be adjusted by a specific dllar amunt set fr each perfrmance standard. Cntractr must prvide a crrective actin plan. Required t d 4 quality imprvement initiatives per year, starting in year 2 f the cntract Gals fr the ASO include: imprve quality f publicly funded BH care, prmte recvery, and imprve management f state resurces and increase FFP fr BH. 3 Infrmatin btained frm Cnnecticut Behaviral Health Recvery Plan RFP, June 30, Infrmatin abut Cnnecticut Behaviral Health Partnership available at: Supprted by a grant frm the Rbert Wd Jhnsn Fundatin s State Health Refrm Assistance Netwrk. 4

5 detxificatin Psychlgical/ neurpsychlgical testing Adult day treatment Hme based fr children Hme health agency Medicatin assisted treatment Mental health grup hmes Extended day treatment Observatin bed at acute care hspitals Additinal grant cvered (e.g. psychscial rehab, ACT) fr individuals with SPMI and/r substance abuse disrders nt in purview f ASO, but ASO must wrk cllabratively with lcal mental health authrities (wh deliver and manage fr SPMI ppulatin). ASO t prvide data t LMHAs regarding utilizatin t imprve crdinatin f care. Supprted by a grant frm the Rbert Wd Jhnsn Fundatin s State Health Refrm Assistance Netwrk. 5

6 IA 4 Statewide BHO. Cvered mental health Full risk cntract. Perfrmance indicatrs with incentives: Braided funding: Mental Health Readmissins rate Inpatient MH Medicaid, state nly f admissin at 7, 30, 90 days Outpatient MH funds, blck grant funds Cmmunity Tenure average # f Services thrugh CMHCs Incentive payments (up t $1,000,000 per cntract days between MH hspitalizatin per cntract perid shall nt fall Service prvided by year) based n belw 94 days licensed scial perfrmance indicatrs. Integrated and Supprts wrker fr treatment f mental illness r SED; licensed psychlgist fr testing/evaluatin Disincentives based n perfrmance. Reinvestment: 2.5% f mnthly cap payment placed in interest bearing at least 18% f MH expenditures used fr integrated ER utilizatin less than r equal t 8.5 visits per 1,000 member mnths Fllw-up after hspitalizatin fr Crisis and emergency accunt and culd be used t fund additinal mental illness within 7 days fr 90% f enrllees Mbile cunseling (b3) r training and Fllw-up after hspitalizatin fr Targeted case management utreach activities (with state apprval). substance abuse treatment within 14 days fr 60% f enrllees ACT Implementatin f MH discharge Hme Health Services plans 94% implemented Treatment f the dually diagnsed Services in state mental institutins fr under 21 and ver 65 25% receive MH and SA treatment fllw up within 7 days, 50% within 30 days Medicatin management Prescriptin medicatin is thrugh FFS Cvered substance abuse Outpatient treatment Netwrk management full implementatin f prvider prfile reprting and netwrk management requirements as in RFP. Perfrmance indicatrs with disincentives Cnsumer invlvement new enrllee infrmatin prvided Mental health discharge plan Braided funding addresses the patchwrk f funding frm multiple agencies fr BH, but it is difficult t manage administratively. 4 Infrmatin btained frm the Iwa Plan (Medicaid behaviral health managed care) cntract (Magellan), January 1, 2010, available at: and frm crrespnding RFP (RFP Med ). Supprted by a grant frm the Rbert Wd Jhnsn Fundatin s State Health Refrm Assistance Netwrk. 6

7 Ambulatry detxificatin discharge plan n day f discharge fr 90% f enrllees Intensive Outpatient Discharge t hmeless r Partial hspitalizatin emergency shelter shall nt Residential treatment exceed 1% f MH inpatient and detxificatin discharge fr under 18 Inpatient treatment Fllw-up n ER visits within 3 and detxificatin days fr 95% f enrllees Emergency Participatin in jint treatment Ambulance planning cnferences at least fr substance abuse 20/mnth, 450 per year cnditins Fllw-up after hspitalizatin fr Services part f substance abuse treatment within substance abuse 30 days fr 63% discharged frm treatment (e.g. 24-hur substance abuse ldging, rehab Substance abuse treatment cunseling, discharge plan discharge plan n diagnstic testing day f discharge fr 90% f specific t substance enrllees abuse treatment, etc.) Claims payment Screening/evaluatin Appeal reviews Grievance reviews Netwrk management The state has sme mnitring nly perfrmance indicatrs as well Supprted by a grant frm the Rbert Wd Jhnsn Fundatin s State Health Refrm Assistance Netwrk. 7

8 NM 5 Statewide BHO Medicaid cvered fr adults and children include: Psychiatric inpatient hspital at a psych unit in a general hspital 23 hur bservatin Inpatient prfessinal by a BH prfessinal Partial hspitalizatin Hspital utpatient Outpatient behaviral health prfessinal (evaluatin, testing, assessment, cunseling and therapy) Cmprehensive cmmunity supprt Telehealth Pharmacy Intensive utpatient fr substance abuse and cccuring disrders Medicaid adults -nly include: Psychscial rehab Braided funding: Medicaid; Children, Yuth and Families Department; Department f Health; HSD/Behaviral health divisin; New Mexic Crrectins Department; New Mexic Aging and Lng Term Services Department. Full risk cntract with capitated payment. Reinvestment: 4.5% f ttal amunt f the HSD managed care revenue applied tward value added ( nt included in the Medicaid benefit package) and cmmunity reinvestment. Cmmunity reinvestment used fr cllabrative apprved prjects that expand capacity f cmmunities t deliver sustainable. In additin, the statewide entity must make available $250,000 fr cmmunity reinvestment n tp f the 4.5%, which can be used Required t have a quality management/quality imprvement prgram fr cntinuus mnitring and evaluatin; QM/QI plicies and prcedures must emphasize and prmte preventin and care crdinatin. Statewide entity must track perfrmance measures, establish baseline and track changes ver time. Failure t achieve perfrmance targets may result in sanctins. The Cllabrative will identify perfrmance targets fr which sanctins are applicable. Pririties include: t expand pilt prjects and ther needed, imprve cmmunicatin with and t tribal cmmunities, imprve cmmunicatin with ther state cntractrs (The Salud!, CLTS, MCOs, SCI), and imprve training and wrkfrce develpment. Same issues with braided funding as in IA example. Integrating care with physical health side is a challenge. Disputes ver payments between physical health and behaviral health MCOs can be an issue. 5 Infrmatin btained frm Optum Health wesite: and RFP fr Medicaid managed care cntract fr FY , available at: T nte, New Mexic is mving t a carve-in mdel. Supprted by a grant frm the Rbert Wd Jhnsn Fundatin s State Health Refrm Assistance Netwrk. 8

9 ACT t purchase any licenses Medicaid child-nly include: assciated with Addictin Severity Index Psychiatric inpatient hspital in a free standing psych hspital Multimedia Versin. Behaviral health utpatient Accredited and nnaccredited residential treatment center Grup hme Treatment fster care Day treatment Multi-systemic therapy Behaviral management skills develpment Cunseling, evaluatin, therapy in a schl based setting NY 6 Reginal ASO. Respnsible fr ppulatin receiving behaviral health inpatient n a Medicaid FFS basis. Duals are excluded. ASO des nt pay claims. Will develp and implement a quality assurance prgram State will use claims data t mnitr key system perfrmance metrics. Additinal metrics will be cllected and prvided by the ASO. Based n data frm the ASO and Medicaid Key gal fr NY is t increase quality and efficiency, and reduce Medicaid csts. Gal and purpse f ASO/BHO is t mnitr behaviral health inpatient length f stay, 6 Infrmatin btained frm New Yrk RFP, June 24, T nte, New Yrk is mving frm an ASO t BHO mdel in 2013; in NYC ne entity will manage all behaviral and physical health benefits fr the SMI ppulatin. Supprted by a grant frm the Rbert Wd Jhnsn Fundatin s State Health Refrm Assistance Netwrk. 9

10 ASO must mnitr, review and asses the use f BH inpatient claims, OMH and OASAS will analyze several dmains f system perfrmance, such as: reduce unnecessary BH inpatient hspital days and readmissin rates, imprve care, mnitr discharge planning activities and facilitate timely cnnectin t pstdischarge Access expectatin that access t apprpriate BH will be maintained as managed care strategies implemented rates f engagement in utpatient and pst discharge, test metrics f system perfrmance, and prfiling prvider, Enhanced activities fr: (1) stateidentified subsets that are disengaged frm care; (2) individuals readmitted fr inpatient care; (3) Engagement in treatment and cntinuity f care expectatin that individuals wh have been hspitalized will be engaged in apprpriate fllw up upn discharge perfrmance. individuals wh had multiple admissins Inpatient length f stay apprpriate duratin fr detxificatin. Additinal Readmissins expected t decrease respnsibilities including tracking SED children s utpatient utilizatin, prvider prfiling and facilitating crss system linkages. Acceptability pstdischarge individuals will be referred t with prviders that ffer which individuals find useful enugh t cme back a secnd time Pp. Carve Out AZ 7 Maricpa cunty. As f Octber 2013, RBHA will be respnsible fr managing all physical and behaviral health fr SMI Full risk cntract. AZ des nt intend fr any subcntracting. Lking at payment mdel that includes incentives. TBD This mdel is still emerging, thus cnclusins cannt yet be drawn. Ptential benefits include: Integratin f creates alignment f 7 Infrmatin btained frm direct cmmunicatin with state fficials and state website: Supprted by a grant frm the Rbert Wd Jhnsn Fundatin s State Health Refrm Assistance Netwrk. 10

11 ppulatin, including dual eligibles. Intent is fr RBHA t health systems. als be a Medicare Advantage SNP, and t be clsely linked management. t prvider-based SMI health hmes. financial incentives acrss physical and behaviral Access t full range f data allws fr effective care Leveraging specialty knwledge f the behaviral health system t serve a ppulatin that it knws best. Beneficiaries have seamless access t benefits and. Ptential challenges include: Identifying plans with sufficient capacity acrss physical and behaviral health t adequately and effectively deliver Determining whether versight shuld sit within Medicaid r the mental health agency cunterparts. Supprted by a grant frm the Rbert Wd Jhnsn Fundatin s State Health Refrm Assistance Netwrk. 11