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NYAPRS EXECUTIVE SEMINAR April 28, 2011 Empire State Plaza, Albany
Magellan’s Medicaid Experience • Public sector focus - 60% of Magellan’s Revenue is Medicaid • Manage behavioral health care for 1.5 million Medicaid members for 8 health plans in 12 States through subcontracting agreements • Contract directly in 5 states representing 13 contracts (Arizona, Florida, Pennsylvania, Iowa, and Nebraska), for 1.9 million members • Pharmacy Benefits Administration Experience in 25 States and • DC
Magellan: Medicaid Expertise All public sector programs are unique but leverage core competencies: • Resources & Experience – Dedicated public sector teams working locally in each State; national experts who provide implementation expertise and ongoing technical assistance/support. • Infrastructure – Specialized BH IT, claims and QI technologies customized for State and Health Plan customers. Focus on outcomes for members and families. • Flexibility- understanding of the unique needs of each State; customized clinical and provider initiatives that address service gaps. • Dynamic Service Array – Track record expanding and enhancing local service delivery systems to focus on community-based programs, peer support, wraparound services and services that promote recovery goals. • Partnership – Collaborative program design and oversight models that engage consumers, family members, providers and other stakeholders in the decision-making process. • Integration – Coordinated approach to physical and behavioral health, including holistic treatment planning and medication management.
Experience with ACO-Like Models • Key elements in behavioral health approach to ACOs/Health Homes: • Experience working with persons with SMI; assisting individuals to manage their behavioral health symptoms • Experience coordinating and managing the care of persons with a mental health or both mental health and substance abuse diagnosis; and physical health/medical diagnosis • Co-location of behavioral health teams with health plans or MCOs • Data sharing within and across systems to create recipient profiles • Partnering with State customers utilizing Section 2703 of the PPACA: • A state may amend its Medicaid plan to provide for medical assistance to individuals with chronic health conditions who select a provider or health team as the individual's "health home" for the provision of home health services. • During the first two years that the State Medicaid Plan amendment is in effect, the federal medical assistance percentage or "FMAP" (the federal government's share of a State's expenditures for Medicaid) is 90%.
Examples of ACO-Like Models • Maricopa County, Arizona: • Global payments to Provider Network Organizations (PNOs) who are accountable for individual and program outcomes: • Publicly-available on-line ‘dashboards’ promote PNO transparency and accountability • Florida: • Sub-capitated payments for outpatient care provided to enrollees in the Prepaid Mental Health Plan (PMHP)
Behavioral Health Approaches & Savings Savings can be achieved through care management approaches Magellan has achieved savings without reducing outpatient provider rates by use of peer programs and community supports diverting members from emergency rooms and reducing inappropriate admissions to inpatient care Savings can be achieved while meeting recovery and wellness objectives, and meeting quality improvement goals Continuous care management efficiencies within mature Medicaid programs Field care management (6% savings on cost of care in a mature program) Targeted efforts in 2 mature programs (5-6% savings on cost of care) Reduce readmissions Decrease inpatient lengths of stay Decrease residential treatment utilization Reduce admission to inpatient care
Collaborating with Providers to Improve Performance • Provider Dashboard • Increase provider accountability and performance • Measure key indicators designed to improve recipient outcomes • Data shared via Web – electronic provider benchmarking improves care while incurring minimal costs • Performance-based Contracting (PA) • Reward for quality – varies by provider based on level of care • Reduce ALOS, improve outcomes while containing costs • Reward for Quality (IA) • Providers with demonstrated positive outcomes subject to less frequent review/oversight • Reduces administrative burden on providers, while promoting and leveraging provider best practices
Persons with SMI and co-morbid conditions are best served in a BH centered IHH due to unique capabilities and expertise required to treat persons with SMI Creative and innovative uses of health information technology Integrated member service record Comprehensive view of member’s past and current medical, behavioral, and pharmacy services More efficient and streamlined coordination of health services Superior anticipated outcomes Improved clinical indicators Better experience of and satisfaction with care Cost savings through reduced ER visits, hospitalizations, and re-admissions to intensive levels of care IHH: A Comprehensive Solution • Integrated health homes featuring behavioral health providers as the clinical lead for care
Barriers to Care Coordination Primary Care Behavioral Health Substance Abuse Specialists Difficulty keeping primary care and bhvisits Physician’s offices often not set up to care for individuals with SMI Issues with literacy and health literacy Anxiety from unaddressed physical issues Clinical gaps in care Issues with transportation More likely to die by suicide Likely to die 25 to 30 years younger 78% Unemployed ER/Urgent Care 15% have diabetes At least 75% smoke tobacco 40 – 60% of those with schizophrenia are overweight Surrounded by others with similar issues High prevalence of co-morbidities Hospital Admission Very low Income / poverty Difficulties with medication side effects and adherence INDIVIDUAL CHALLENGED WITH MENTAL HEALTH AND/OR SUBTANCE ABUSE
Essential Elements of Integrated Health Home • Overview • Behavioral health is the gateway to improved health outcomes through this model, leveraging expertise in utilizing peer support, community resources and telemedicine. • Basic primary care functions are administered via the BH team, whether in a CMHC or other BH clinic setting. • The BH lead also coordinates more intensive medical care, including specialists and follow-up from hospital care. • Patient registry tools track outcomes and drive accountability. 1 Member engagement, peer support, and family support 2 Use of community resources Outcomes and accountability 1 2 3 Behavioral Health as Lead Coordinator 6 3 4 Enhanced provider coordination / pharmacy management Increased access to care, including use of telemedicine Provision of basic physical health services 5 5 4 6 SpecialtyCare HospitalCare
PA HealthChoices/HealthConnections Case Study • “ Develop a best practice in which a behavioral health carve-out (Magellan) and a Medicaid physical health plan in southeastern PA partner together to improve the connection and coordination of care for adults with serious mental illness enrolled in the HealthChoices Medicaid program. “ Value Proposition • Serves Medicaid adults diagnosed with schizophrenia, mood disorder, or borderline personality disorder • Two-year pilot program established and monitored by the Pennsylvania Department of Public Welfare • Services include integrated member profile, including pharmacy data, for participants; multiple clinical touch points between physical and behavioral system; community-based ‘navigators’ who facilitate tx coordination Program Summary • Decreased inpatient admissions and ER visits • Member service profile and integrated health/wellness plan developed for each member • Timely notification to prescribers about medical refill gaps Desired Outcomes Preliminary Results • Improved coordination of care: • 100% of members connected with PCP • 100% of members connected with appropriate behavioral health services • 89% made or sustained progress meeting substance abuse recovery goals • 93% of participants connected to a medical specialist • Utilization changes: • BH outpatient utilization increased, • ER and inpatient utilization for physical health decreased
Magellan’s Peer Initiatives Peer experience is valued and integrated at all levels of our Public Sector programs • Peer specialists work in our care management centers and national team • Peer-provided services and supports through our provider network • Partnerships with peer-operated organizations in communities we serve • Promotion of mutual self-help and support groups as a vital resource for recovery Peer Support as an evidence-based practice is implemented through approaches that work • Peer Crisis Navigators help link people to services to prevent ongoing crisis involvement (AZ) • Peer Connections and other bridger-type programs help people coming out of hospitals (PA and FL) • Peer specialists trained to provide crisis support (IA) • Peer Support Whole Health – rolling out across all Public Sector programs. • Currently in place in Maricopa, Pennsylvania, and Iowa.
Recovery, Resiliency & Wellness Initiatives Promote Improved Outcomes • Peer Support Whole Health initiative promotes individual success in achieving personal health goals • Participants set goals to address specific health/wellness issues • Targeted education sessions and activities (walking clubs, phone trees for smoking reduction, relaxation and stress groups) to assist participants in meeting their goals • Services billable to Medicaid as peer/family support, living skills, health promotion • Passport to Care • Educates recipients on importance of physical health care, prevention • Tools and techniques to assist recipients in talking with their PCP, sharing critical BH information such as pharmacy and labs • Continuing commitment to implement across all Public Sector programs • 250+ peer specialist trained in PSWH in partnership with Appalachian Consulting Group since 2009 • Peer Support Whole Health part of Integrated Health Home pilots • Expect an additional 150 peer specialists to be trained this year
Recovery, Resiliency & Wellness Initiatives Promote Improved Outcomes • Arizona Smokers’ Helpline (ASH) • Provides Medicaid recipients with free telephonic and on-line resources to stop smoking, which in turn improves overall health outcomes • Includes “Personalized Quit Plan” to help participants meet their smoking cessation goals • Resources available in Spanish and English • Peer Crisis Navigators • Implemented in 2010 in Maricopa County – links individuals in crisis to community outpatient treatment • Used as both step down and diversion • Peer navigators assist those in need, break cycle of repeat crisis episodes • Contract with a peer organization to provide warm line service
Recovery, Resiliency & Wellness Initiatives • Youth in Transition - Magellan Youth Leaders Inspiring Future Empowerment (MY LIFE) – AZ, PA • Awardee at NMHCC National Convention 2011 • Youth-led initiative in which young people develop their own service solutions • Improves the systems of care for youth in transition • www.magellanofaz.com website – extensive tools and resources • Recovery and Resiliency learning center – 10 webinars on diverse recovery/resiliency topics; four webinars on Peer Support • Outcomes dashboard showing program performance in key areas
Recovery, Resiliency & Wellness Initiatives • Self Directed Care • Persons with SMI (Iowa) • Person-centered planning, life coaching, individual budgeting, financial management, expanded provider networks and services • Participants work within a “budget” to “purchase” both traditional Medicaid services and other, non-traditional goods and services that support their recovery and resiliency plans • Families with Children with Autism (Pennsylvania) • Children with a diagnosis along the autism spectrum and their families received funds to purchase products and services not otherwise covered by insurance • Funds used for activities to encourage interaction with family members/peers. Other families purchased computers and other media to increase their child’s communication skills • Families empowered to take leadership role in their own treatment process • Children’s System of Care • Goal: Maintain at-risk children with families/caregivers, in their communities • Care coordinated by dedicated clinicians with expertise in children’s issues • Access to a range of specialized child/family resources • Joint treatment planning with schools, medical providers, families, caregivers
Participation in Maricopa County Continuum of Care on Homelessness Committee: Multi-agency committee that includes Government representation, agency members, formerly homeless individuals and advocates Committee develops strategies to access Federal and local HUD funds Magellan provides dollar-for-dollar match in the form of case management, wraparound services to support housing initiatives Also provides technical assistance in development and submission of renewal/new grant applications Housing and Urban Development (HUS) Point-in-Time Homeless Count: Federally-mandated point-in-time survey to gather data on numbers, characteristics of homeless individuals Magellan staff volunteer time to participate in annual survey Survey data used to justify additional funding requests, prioritize housing development Includes sub-survey that profiles homeless and chronically homeless veterans Project Homeless Connect: Monthly ‘one-stop shop’ that provides immediate access to an array of social and support services to homeless/chronically homeless individuals Behavioral health assessment and crisis evaluations with clinical professionals Provided in partnership with local provider agencies that specialize in services to homeless individuals Homeless/Housing Initiatives • Since 2007, Magellan has facilitated addition of 3,911 new units of subsidized and transitional housing in Maricopa County, AZ – an increase of 15% in total units available
Project for Assistance in Transition from Homelessness (PATH): Partnership with AZ Department of Health Services and Southwest Behavioral Health Services Outreach for homeless individuals not currently engaged in BH services to help them find treatment and housing Quarterly meetings to identify barriers, find solutions to increase housing availability SAMHSA’s national PATH consultant has provided presentations and program assessment support Bridge Subsidy Program (BSP): Collaboration between Magellan, Public Housing Authorities (PHAs) and non-profit organizations Provides linkages and housing for persons with serious mental illness using a Housing Choice Voucher (HCV) system Features the Permanent Supportive Housing (PSH) model (a national best practice) that provides permanent housing, typically rentals, for members. The BSP provides transitional funding to help eligible recipients until they can apply for HUD’s Section 8 HCV. It also applies for additional Section 8 vouchers when they become available Corporation for Supported Housing, Tempe AZ Multi-agency collaborative that includes Magellan – Federal stimulus funds used for rent/utilities Created, funded and implemented 35 units of permanent supported scattered site housing for chronically homeless individuals Magellan provides ‘supportive services teams’ to individuals to ensure their ongoing stability Homeless/Housing Initiatives
Preparing to Become a SNP Provider We look to NYAPRS and its member providers to provide input, partnership and guidance during the transition to an SNP system. Areas for consideration include: • PCP/Specialty Health Provider Coordination • Majority of SNP eligible individuals will have complex care needs, both medical and behavioral • Foster collaborative relationships with PCPs, other specialty systems • Co-sponsor meetings with primary care system to establish common understanding of challenges and potential solutions
Preparing to Become a SNP Provider • ClinicalDocumentation • Review existing clinical documentation (initial assessment, treatment plan, discharge planning documentation) to ensure inclusion of: • Coordination with PCP • Medication management • Recovery and resiliency focus Technology Competency • Develop Readiness for Electronic Medical Record requirements • Ensure system has functionality for comprehensive connectivity, data sharing