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What’s Hot: Other States and Their SUD Efforts Under PPACA Controversies over Utilization, New Focus on Utilization Management. Suzanne Gelber Rinaldo, MSW, Ph.D. The Avisa Group San Francisco CADPAAC March 23, 2012.
What’s Hot: Other States and Their SUD Efforts Under PPACA Controversies over Utilization, New Focus on Utilization Management Suzanne Gelber Rinaldo, MSW, Ph.D.The Avisa Group San Francisco CADPAAC March 23, 2012
Other Large States: Some News about SUD Benefits Under PPACA/Medicaid Reform • Pennsylvania • Minnesota • Texas • New York • Large states that are reported to have interesting programs: New Jersey, Maryland The Avisa Group
Pennsylvania • In many ways, PA is more like CA than other states: • Extremely diverse population, • Large urban and large rural populations • County-led state with strong substance abuse county and state programs • Strong, policy-oriented provider association in substance abuse The Avisa Group
Pennsylvania HealthChoices • Started in 1997, continuing under PPACA • Counties have the right of first opportunity to apply competitively to the state to be the vendor for the behavioral health and health services delivery systems for Medicaid recipients; many have done so, like Philadelphia • State has competitively selected mbho’s in counties that did not apply The Avisa Group
Pennsylvania • PA created capitated program for the Commonwealth • OMHSAS successfully implemented HealthChoices in 25 counties so far (3 zones) • Approximately 895,000 Medical Assistance enrollees covered • www.cbhnp.org/behavinfo.aspx The Avisa Group
PA Covered SUD Services • Services covered in plan only (no out of network but there are supplemental services available if approved, plus varied remaining SUD services in counties • SUD Benefits: • . Crisis Intervention (including psychiatric) • Outpatient Drug and Alcohol Treatment, including evaluation and individual/group therapy • Methadone/MAT The Avisa Group
PA Covered SUD Services • Drug and Alcohol Detoxification (in hospital, ambulatory or approved facility) • Behavioral Health Rehabilitation Services for Children and Adolescents (includes SUD, wraparound) • Non-covered services: residential treatment for SUD – not in plan, no approval, result in service denial • CBHNP works with other agencies, PCP’s, area and county agencies, social services to help organize treatment and support The Avisa Group
Minnesota • Medicaid (MA) and MinnesotaCare (expansion population) have SUD benefits • MA covers alcohol and drug treatment (state has always had a strong SUD agency) • Dual eligibles pilot program includes full integration of medical care, behavioral health, LTC and community services The Avisa Group
Hennepin County: Minneapolis and environs • County has largest population in state • Long history of providing services • Created an ACO to cover MA expansion population • Combines behavioral health, social services, countywide services • Crosses over to include criminal justice and social services for clients who need support The Avisa Group
Texas • One of three states (TX, FLA, WISC) that are not formally implementing PPACA • Nevertheless, SUD services are being provided in a health-reform “lite” fashion • Unusual requirement: legislation covering new SUD program in Medicaid (as of 1/1/2011) states that services are tied to what is fiscally supported by the state’s Legislative Budget Board • State is allowed to discontinue SUD services under Medicaid via this legislation, if providing services increases overall Medicaid costs The Avisa Group
Texas: New Covered Benefits under Medicaid Began 2010 • Covered Services 2010: Can petition for more • Assessment, no prior authorization required; ambulatory outpatient treatment (135 hours of group plus 26 hours of individual per year); MAT – can be provided by MD’s and by CDTF’s approved by state; ambulatory detoxification (Only in CDTF Medicaid enrolled facilities, must have prior authorization (electronic), up to 35 days per episode with a limit of 2 in six months The Avisa Group
Texas: Other Medicaid SUD Services • 2011: residential detoxification, prior authorization, must be medically necessary • Special services for pregnant women and their children, not many approved vendors (wraparound) • MAT for adolescents, up to 20 sessions • RTC services for adolescents • Not covered: aftercare, telemedicine, TCM • Retrospective review done on all claims • Medicaid Chief is retiring – could lead to change The Avisa Group
New York • SUD benefit reform is part of wholesale SUD service reorganization in NYS that created the former MATS (covered case management) • NY is phasing in Medicaid managed care geographically, now downstate/NYC • NY State explicitly invoked the “good and modern” system ideas from SAMHSA • Both Medicaid managed care and Family Health Plus cover SUD services The Avisa Group
Chemical Dependence Benefit Package Summary The Avisa Group
New York Chemical Dependence Benefit Package Summary The Avisa Group
NY’s New Health Home Program Changes the SUD System Again • Existing benefits include access to full continuum of care including crisis/detox, inpatient, long-term residential, supportive housing and outpatient services including MAT • Care coordination has become the key and has replaced case management as of April 2012 • First wave of health home projects includes individuals with chronic SUD/MH The Avisa Group
Managed Medicaid, New York Health Homes/UR • Entire system is subject to SUD utilization review for level of care determination • State wants UR tools to determine specific clinical needs of SUD patients, use accepted SUD assessment tools • Issue: Court-ordered vs. MCO clinical necessity criteria • Visit thresholds do not acknowledge differences in patterns of SUD service delivery • Still are pushing but do not yet have reviewers with spcific SUD credentials and experience • Still pushing for SBIRT as part of Health Home patient assessments • Phase I BHO’s need to be active in Health Home enrollment, assignment and service delivery (needs push) The Avisa Group
NASADAD vs. Cappocia on Effects of State Health Reform (MASS, Vt., Maine) • NASADAD issued a 2010 statement that “after health care reform, “both access and demand rose in each state” • Acknowledged that the uninsured rate amongst those with SUD remained high • Asserted that savings were realized through ASO’s (Administrative Services Organizations) • Pointed out challenges: enforcing parity, addressing workforce shortages, increasing administrative costs to SUD treatment providers The Avisa Group
Capoccia • Capoccia et. al (Health Affairs 31, No. 5, 2012) concluded that the experience of Massachusetts shows that health reform incorporated SUD services into essential benefits for all covered residents • Analysts expected an increase in access, utilization • Actual experience as assessed showed: • Stable use of SUD treatment before and after reform, large percentage of SUD patients remained uninsured • Many covered SUD patients were deterred from use by requirements for copayments, increased eligibility requirements, utilization review stringency, lack of outreach • Qualitative and quantitative findings were in accord: no increase in admissions to treatment but revenues rose for treatment agencies nevertheless • Inconsistent clinical criteria cited; NSDUH projections may be inflated • Absence of redesign in SUD treatment system may be an issue • Ineffective outreach: needs much more of a focus The Avisa Group
Utilization Review and Management • Has moved in theory and practice from just say no to more sophisticated management of care • Clock can be set for different times • Requires consistent, published criteria, not ad hoc or invites lawsuits • In place already in some counties but not fully implemented in many • Reviewers need to use accepted protocols, have SUD training and experience but sometimes this is not the case • Reinforces role of medical directors • Very confusing for some patients/families • Used alone does not result in savings in absence of system changes • May be in conflict with parity law The Avisa Group