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Evaluation Results of the Prepaid Mental Health Demonstration: Year 7 - Areas 1 and 6 Briefing for the Substance Abuse and Mental Health Corporation August 4, 2004. David L. Shern, Ph.D. and the Evaluation Team Louis de la Parte Florida Mental Health Institute. Framing Evaluation Questions.

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david l shern ph d and the evaluation team louis de la parte florida mental health institute

Evaluation Results of the Prepaid Mental Health Demonstration: Year 7 - Areas 1 and 6Briefing for the Substance Abuse and Mental Health CorporationAugust 4, 2004

David L. Shern, Ph.D.

and the Evaluation Team

Louis de la Parte Florida Mental Health Institute

framing evaluation questions
Framing Evaluation Questions
  • What are the implementation issues related to systems redesign and expansion?
  • What is the impact of managed care on Medicaid enrollees’
    • Access to care?
    • Health and mental health status?
    • Costs of care?
integrated sub studies
Integrated Sub-Studies
  • Implementation Analysis
    • Review of Contracts
    • Surveys of Key Informants and Stakeholders
  • Administrative Data
    • Medicaid Enrollment and FFS Claims
    • Managed Care Encounter Data
    • Pharmacy Claims Data
    • Global Functioning Measures for Service Users
  • Adults with SMI Intensive Interview Study
    • Mental Health Status and Satisfaction Data
    • Social Cost Analysis
  • Medicaid General Population Mail Survey
description of the provider networks
Description of the Provider Networks

Area 6

  • HMOs primarily use the 5 main Community Mental Health Centers in the area
    • All Fee-For-Service in the beginning
      • Shifted to capitation over time, but some

Fee-For-Service still present

  • PMHP uses the same 5 Community Mental Health Centers - stable structure over time
    • Use risk adjusted capitation to Community Mental Health Centers
slide6

Area 6 Funding Streams as of 4/04

Agency for Health Care Administration

SA, SIPP, FACT, BHOS,

STFC, & Comprehens. Assessment

FHP/VO

STAY

HE

AmG

UHC

MG

MHC

WBH

UBH

Northside

Medicaid enrollees not eligible for managed care

PR

WH

AssociateProv.

CommunityMental Health Centers

Providers

Other Providers

Solid line – Capitation

Dotted line – Fee for service

provider networks
Provider Networks

Area 1

  • The PMHP and HMO have different provider networks
  • Fee-For-Service for HMO Relationships
  • Capitation for PMHP
slide8

Area 1 Funding Streams as of 6/04

Agency for Health Care Administration

SA, SIPP, FACT, BHOS,

STFC, & Comprehens. Assessment

ABH

LVC

HE

WCBH

BW

Medicaid enrollees not eligible for managed care

COPE

Associate

Providers

Providers

(excluding LV)

Providers

Solid line – Capitation

Dotted line – Fee-for-service

slide10
The HMO Business Arrangements Have been Accompanied by Greater Instability and Complexity in Organizational Arrangements
slide11

Organizational Structure: Funding Streams as of 1/00

Agency for Health Care Administration

St.A.

FL 1st

PHP

STAY

UHC

HE

PCA

ALP

FHP

MG

Value

Options

MHC

WEL

MAG

APS

Horizon

UBH

CBC

Northside

BHM

MHC

(CMHC)

PR

MHC

(CMHC)

WH

AssociateProv.

Community Mental Health Centers

Other Providers

slide12

Area 6 Funding Streams as of 3/02

Agency for Health Care Administration

FHP/VO

FL 1st

STAY

ST.A

PHP

HE

UHC

MG

MHC

HZ

CBC

UBH

Northside

PR

CMHC

WH

AssociateProv.

Community Mental Health Centers

Other Providers

Black = FFS Blue = Outpatient capped only

Red = Outpatient & Inpatient capped Dotted line = Risk Sharing

slide13

Figure 6. Area 6 Funding Streams as of 4/04

Agency for Health Care Administration

SA, SIPP, FACT, BHOS,

STFC, & Comprehens. Assessment

FHP/VO

STAY

HE

AmG

UHC

MG

MHC

WBH

UBH

Northside

Medicaid enrollees not eligible for managed care

PR

WH

AssociateProv.

Community Mental Health Centers

Providers

Other Providers

Solid line – Capitation

Dotted line – Fee for service

slide17

People with Schizophrenia enrolled in HMOs, which are at risk for pharmaceutical expenses, are less likely to receive atypical antipsychotic medications

slide19
Enrollees are Receiving Fewer Services or Less Intensive Services in the Managed Care Conditions

HMO Enrollees Receive Fewer Services than Persons in the PMHP

slide22

Reduced Intensity of Services has Generally Not Been Associated with Poorer Outcomes for Managed Care EnrolleesYouth in Area 1 Require Further Study to Explain Poor Outcomes

change in predicted gaf score over time for ages 21 64 in areas 1 2 and 4 n 5 278
Change in Predicted GAF Score Over Time For Ages 21-64 in Areas 1, 2, and 4 (n=5,278)

Financing Conditions differ p <.001

Time p < .001; Interaction - NS

slide24

Based on Our Social Cost Analysis, Reduced Intensity of Services for Medicaid-Funded Services May be Offset by Higher Expenditures by Other Payers

slide25

Case-Mix Adjusted Annualized Costs for Adults with Severe Mental Illnesses

* Medicaid costs include health care and transportation.

** Other public costs include off budget health care cost, housing subsidies, legal service, and volunteer cost.

***Private costs include informal service provided by families/friends, earned income, and out of pocket fee if earned

income equal to zero.

service recommendations
Service Recommendations
  • Set Access Targets for Carve-Out Services at Pre-Implementation Levels at a Minimum in All Areas
  • Assure that the Service Network is Adequate to Provide Services to Persons with More Severe Illnesses
service recommendations1
Service Recommendations
  • Assure Provision of Evidence Based Care for both Treatment and Rehabilitation
    • Fidelity Measurement
    • Benchmarked Outcome Data
  • Explore Methods to Appropriately Expand Consumer Knowledge about and Direction of Care
    • Particularly for Persons with More Chronic Care Needs
organizational recommendations
Organizational Recommendations
  • Implement Strategies to Independently Assure Adequacy of Data for System Monitoring
    • Anticipate the Loss of Outcome Data for Networks Like those Used in Area 1 HMO
    • Investigate Methods for Independently Collecting Encounter Data Including Sources of Care from Other Public and Private Payers
organizational recommendations1
Organizational Recommendations
  • Assure Readiness to Provide Comprehensive Mental Health Benefits
    • Demonstrated Capacity in MIS
    • Demonstrated Management Capacity for Authorization and Payment
    • Adequate Transition Strategies and Ramp-up Time
organizational recommendations2
Organizational Recommendations
  • AHCA Should Develop, Test and Implement a Method to Assure Compliance with the 80% Rule
    • Incomplete Encounter Data Frustrates Adequate Monitoring
  • Consider Expanding Range of Carve-Out Services to Limit Cost Shifting within Medicaid Budgets
    • Carefully Monitor Access to Specialized Services for Managed Care Enrollees
    • Exclude Pharmacy Benefit and Explore other Methods to Control Pharmacy Costs
    • Include Substance Abuse Services with Adequate Capitation Rate
organizational recommendations3
Organizational Recommendations
  • Coordinate Efforts with DCF and Other Relevant Providers (Child Welfare, JJ, etc.) to
    • Reduce Cost Shifting Among Public Payers
    • Assure Most Effective and Efficient Delivery Strategies
framing evaluation questions1
Framing Evaluation Questions
  • What are the implementation issues related to systems redesign and expansion
  • What is the impact of managed care on Medicaid enrollees’
    • Access to care
    • Health and mental health status
    • Costs of care
slide34

Table 9. Annualized Formal Costs for Health Services On and Off Budget (Adjusted)

Health services include general medical, vision and dental care excluding transportation.

* Significant at the 5 percent level. ** Significant at the 1 percent level.

slide35

Managed Care Arrangements, Particularly in the HMO Condition, have been Accompanied by Consistent and Significant Problems with Encounter Data - Frustrating Accountability

slide36

If Managed Care is to Accomplish its Goal of Giving More to the State through Greater Efficiency and Effectiveness of Management, We Must Get More from Managed Care

service recommendations2
Service Recommendations
  • Set Access Targets for Carve-Out Services at Pre-Implementation Levels at a Minimum in All Areas
  • Assure that the Service Network is Adequate to Provide Services to Persons with More Severe Illnesses
service recommendations3
Service Recommendations
  • Assure Provision of Evidence Based Care for both Treatment and Rehabilitation
    • Fidelity Measurement
    • Benchmarked Outcome Data
  • Explore Methods to Appropriately Expand Consumer Knowledge about and Direction of Care
    • Particularly for Persons with More Chronic Care Needs
organizational recommendations4
Organizational Recommendations
  • Implement Strategies to Independently Assure Adequacy of Data for System Monitoring
    • Anticipate the Loss of Outcome Data for Networks Like those Used in Area 1 HMO
    • Investigate Methods for Independently Collecting Encounter Data Including Sources of Care from Other Public and Private Payers
organizational recommendations5
Organizational Recommendations
  • Assure Readiness to Provide Comprehensive Mental Health Benefits
    • Demonstrated Capacity in MIS
    • Demonstrated Management Capacity for Authorization and Payment
    • Adequate Transition Strategies and Ramp-up Time
organizational recommendations6
Organizational Recommendations
  • AHCA Should Develop, Test and Implement a Method to Assure Compliance with the 80% Rule
    • Incomplete Encounter Data Frustrates Adequate Monitoring
  • Consider Expanding Range of Carve-Out Services to Limit Cost Shifting within Medicaid Budgets
    • Carefully Monitor Access to Specialized Services for Managed Care Enrollees
    • Exclude Pharmacy Benefit and Explore other Methods to Control Pharmacy Costs
    • Include Substance Abuse Services with Adequate Capitation Rate
organizational recommendations7
Organizational Recommendations
  • Coordinate Efforts with DCF and Other Relevant Providers (Child Welfare, JJ, etc.) to
    • Reduce Cost Shifting Among Public Payers
    • Assure Most Effective and Efficient Delivery Strategies
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