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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 Demonstration:

  • 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 Demonstration:

  • 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 Demonstration:

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


Area 6 Funding Streams as of 4/04 Demonstration:

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 Demonstration:

Area 1

  • The PMHP and HMO have different provider networks

  • Fee-For-Service for HMO Relationships

  • Capitation for PMHP


Area 1 Funding Streams as of 6/04 Demonstration:

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


What have we learned
What Have We Learned? Demonstration:


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


Organizational Structure: Funding Streams as of 1/00 Greater Instability and Complexity in Organizational Arrangements

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


Area 6 Funding Streams as of 3/02 Greater Instability and Complexity in Organizational Arrangements

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


Figure 6. Area 6 Funding Streams as of 4/04 Greater Instability and Complexity in Organizational Arrangements

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


Implementation of managed care has not resulted in improved access to services
Implementation of Greater Instability and Complexity in Organizational ArrangementsManaged Care Has Not Resulted in Improved Access to Services




People with Schizophrenia Areas 6, 4 and 7 enrolled in HMOs, which are at risk for pharmaceutical expenses, are less likely to receive atypical antipsychotic medications


Atypical penetration areas 4 6 adult schizophrenia diagnosis only
Atypical Penetration Areas 6, 4 and 7Areas 4 & 6 Adult Schizophrenia Diagnosis Only


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

HMO Enrollees Receive Fewer Services than Persons in the PMHP


Pmpm standard costs by category areas 1 2 4 case mix adjusted
PMPM Standard Costs by Category: Services in the Managed Care ConditionsAreas 1, 2 & 4 (Case Mix Adjusted)


Pmpm standard costs by category areas 6 4 and 7 case mix adjusted
PMPM Standard Costs by Category: Services in the Managed Care ConditionsAreas 6, 4 and 7 (Case Mix Adjusted)


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


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


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 Mental Illnesses

  • 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 Mental Illnesses

  • 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 Mental Illnesses

  • 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 Mental Illnesses

  • 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 Mental Illnesses

  • 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 Mental Illnesses

  • 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 Mental Illnesses

  • 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


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.


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


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 and organizational recommendations1
Service and Organizational Recommendations the State through Greater Efficiency and Effectiveness of Management, We Must Get More from Managed Care


Service recommendations2
Service Recommendations the State through Greater Efficiency and Effectiveness of Management, We Must Get More from Managed Care

  • 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 the State through Greater Efficiency and Effectiveness of Management, We Must Get More from Managed Care

  • 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 the State through Greater Efficiency and Effectiveness of Management, We Must Get More from Managed Care

  • 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 the State through Greater Efficiency and Effectiveness of Management, We Must Get More from Managed Care

  • 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 the State through Greater Efficiency and Effectiveness of Management, We Must Get More from Managed Care

  • 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 the State through Greater Efficiency and Effectiveness of Management, We Must Get More from Managed Care

  • 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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