Barbara Mauer, MSW, CMC Dale A. Jarvis, CPA MCPP Healthcare Consulting Inc. Seattle, Washington

1. Behavioral Health, the Changing Healthcare Landscape, and California 1115 Waiver OpportunitiesCiMH WebinarJanuary 5, 2010 Barbara Mauer, MSW, CMC Dale A. Jarvis, CPAMCPP Healthcare Consulting Inc. Seattle, Washington

2. Session Logistics • Tips • Your panel can be minimized by clicking on the double arrow • To ask a question, please type your question in the box and press the Send button • We will be answering questions at the end of each of the 3 “Chapters”

3. Definition of Terms – BH, SA, SU, AOD • These slides use the term “Substance Use Services” and “Substance Use Disorders” to describe the broadest context of Alcohol and Other Drug Services and Disorders, based on the recommendation of the Institute of Medicine’s Crossing the Quality Chasm report • These slides also use the term “Behavioral Health” in a number of places to describe Mental Health and Substance Use • We are still in the process of agreeing on a common language; this is a work in progress and we continue to work toward agreement on the language we use and the integration models we develop and deploy • A paper is forthcoming that adds more depth to the role of SU services in the 4 Q model and the person-centered healthcare home

4. The Behavioral Health “Tipping Point” Hypothesis • We have finally reached the tipping point in understanding the importance of treating the healthcare needs of persons with serious mental illness and the behavioral healthcare needs (MH & SU) of all Americans • Behavioral healthcare has become very important to managing Total Health Expenditures in the U.S. and bending the cost curve • This will drive widespread integration of Primary Care and Behavioral Health in the form of the Person-Centered Healthcare Home and will create greater demand for mental health and substance use treatment services • These changes will bring enormous opportunities and challenges to the Community Mental Health and Substance Use Systems, which will need to demonstrate that they can provide evidence-based, high quality care that produces outcomes and manages total health expenditures

5. “Chapters” to Guide Our Discussion • The National Picture of Health Healthcare Reform • The California IPI Report, Behavioral Health/Primary Care Integration and Person-Centered Healthcare Homes • Key Concepts in Developing a New California 1115 Waiver

6. The National Picture of Health Healthcare Reform Where is National Healthcare Reform Headed and what arethe implications for the PublicBehavioral Healthcare System?

7. The Overall Design for Healthcare Reform • U.S. health care reform legislation has been designed to address three issues • There are 10 key healthcare reform issues relevant to the public behavioral healthcare system

8. 1. Healthcare Reform will Result in Service Delivery Design and Payment Reform The Path to a High Performance U.S. Health System – A 2020 Vision of the Policies to Pave the Wayidentified Health Care Reform Policies that can save $3 trillion over 10 years (Commonwealth Fund 2009)

9. 1. Healthcare Reform will Result in Service Delivery Design and Payment Reform Person-Centered Healthcare Homes (aka Patient-Centered Medical Homes [PCMH]) • 45 percent of Americans have one or more chronic conditions. • Over half of these people receive their care from 3 or more physicians. • Treating these conditions account for 75% of direct medical care in the U.S. • Person-Centered Healthcare Homes is a key strategy

10. 1. Healthcare Reform will Result in Service Delivery Design and Payment Reform Healthcare Home Principles • Ongoing Relationship with a PCP • Care Team who collectively take responsibility for ongoing care • Provides all healthcare or makes Appropriate Referrals • Care is Coordinated and/or Integrated • Quality and Safety are hallmarks • Enhanced Access to care is available • Payment appropriately recognizes the Added Value

11. 1. Healthcare Reform will Result in Service Delivery Design and Payment Reform They are all about Improving Quality and managing Total Healthcare Expenditures! Person-Centered Healthcare Homes

12. 2. Healthcare Reform May Unfold Rapidly Eight key activities begin between 2010 and 2014 Requiring a great deal of implementation effort at the State and Federal levels

13. 3. Healthcare Reform will Usher in an Era of Disruptive Innovation in Healthcare • The problems facing the American healthcare system mirror nearly every other industry in their early phases • Disruptive Innovation is already underway in general healthcare • Healthcare Reform could serve as the tipping point, speeding up the change processes that are already being piloted across the country • This creates opportunities and threats for existing managers and provider of care

14. 4. Behavioral Health is now on the Health Policy Community’s “Radar Screen” Morbidity and Mortality in People with Serious Mental Illness Persons with serious mental illness (SMI) are dying earlier than the general population (average age of death is 53) While suicide and injury account for about 30-40% of excess mortality, 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases (NASMHPD, 2006) OR state study found that those with co-occurring MH/SU disorders were at greatest risk (45.1 years)

15. 4. Behavioral Health is now on the Health Policy Community’s “Radar Screen” • 49% of Medicaid beneficiaries with disabilities have a psychiatric illness (this is new information; previous studies that excluded pharmacy claims calculated the rate at 29%) • Substance use conditions do not show up in this study at the expected levels because it’s based on an analysis of claims and pharmacy scripts The Faces of Medicaid III: Refining the Portrait of People with Multiple Chronic ConditionsCenter for Health Care Strategies, Inc., October 2009

16. 5. Most Members of the Safety Net will have Coverage Including MH and SU Benefits • 31% to 43% increase in Medicaid enrollees, depending on the bill • Large reduction in uninsured (54% to 67%)

17. 5. Most Members of the Safety Net will have Coverage Including MH and SU Benefits • Resulting in significant additional funding • $206 billion of new federal funding; $86 billion for Medicaid expansion and $120 billion for Health Exchange Subsidies • $16 to $25 billion in additional spending for mental health and substance use treatment from insurance expansion • No credible numbers yet on financial impact of Parity Act and how much additional BH spending will be funded out of the “healthcare pot”

18. 6. Parity will Likely Improve Access and Available Services • Mental Health and Substance Use Services must be provided at parity with general healthcare services (no discrimination) • Large Employers (Parity Act) • Medicaid (Health Reform Legislation) • Health Insurance Exchanges for Individual and Small Group Policies (Health Reform Legislation) • Medicare: on the way (Medicare Modernization Act of 2003) • Key for public sector systems isscope of services; will plans cover system of care/FSP type of services?

19. 7. There is No Guarantee that New BH Revenues will Spent on CBHO Services • A recent study of US MH/SU spending estimates that in 2014 less than 16% of U.S. spending on MH/SU services will occur in Community Behavioral Healthcare Organizations [CBHOs] • We should not assume that new behavioral health expenditures will be more heavily weighted towards CBHOs (Note: Figures are summarizedfrom Table A2 of the 2008 SAMHSA Report, “Projections of National Expenditures for Mental Health Services and Substance Abuse Treatment 2004 – 2014”)

20. 7. There is No Guarantee that New BH Revenues will Spent on CBHO Services • One “big idea” is to have Medicare make capitation payments to states to organize and manage Dual Eligible Plans (Medi-Medi) • Given the effort to combine funding, it seems unlikely that Dual Eligible mental health services would be carved out; especially because of the need to address identified co-morbidities • The following example illustrates one PIHP in Washington State

21. 7. There is No Guarantee that New BH Revenues will Spent on CBHO Services The payor environment will be shifting • Medicare already a federal incubator of design changes (Medical Home pilots underway) • Insurance Exchanges, larger Medicaid programs, and new Dual Eligible (Medi-Medi) plans will be the state incubators of design changes Many questions: • How many uninsuredwill go into Exchanges? • How many Dual EligiblePlans develop? • Will CBHOs be on theExchange and DualEligible ProviderNetworks?

22. How soon will this translate into recognizing the need to embed behavioral health clinicians in medical homes and how will these models evolve? Will NCQA add BH capacity as a required element of Medical Home certification? If so, how long will it take for this to occur? Will medical homes partner with CBHOs or hire their own BH staff? Will Accountable Care Organizations [ACOs] (networks of primary care providers pooling medical home support functions) become the employers of the BH clinicians? 8. Total Healthcare Costs of Persons with MH/SU Disorders will Drive Integration, But the Integration Models are Still Evolving

23. 8. Total Healthcare Costs of Persons with MH/SU Disorders will Drive Integration, But the Integration Models are Still Evolving • How quickly will CBHOs prioritize integration, build necessary competencies, and develop relationships with the primary care community to place BH clinicians in medical homes? • How quickly will CBHOs embed primary care capacity in the CBHO setting? If not quickly enough, will this window of opportunity close as CBHO consumers obtain primary care services in other settings? • Will healthcare consultants and MBHOs convince states, exchanges and commercial plans that they should use disease management organizations to provide care coordination services and rely primarily on telephonic care management, potentially removing the opportunity of CBHOs to partner with healthcare homes? Will ACOs do the same? • Will new, innovative provider organizations disrupt both existing primary care clinics and CBHOs in providing integrated primary care and behavioral health services?

24. 9. The Need to Integrate Funding Combined with the Complexity of the Current System may Result in a Rapid Move Away from Behavioral Health Carve-Outs • Different Scenarios will play out across the country • Some states will end their carve-outs “tomorrow” to achieve clinical integration • Others will stay with the status quo and attempt to avoid change • A 3rd group will work with their MH/SUpartners to moveinto the nextgeneration • A 4th group willstay with carve-out model butre-procure theentire system

25. 10. Payment Reforms will be Linked to the Ability to Demonstrate Outcomes and Manage Costs • We are moving from an era of talking about measurement to an era where the ability to operate within a quality improvement and performance measurement framework is an entrance requirement. • Health plans and payors will be looking at how well CBHOs manage total healthcare expenditures of persons with MH/SU conditions and the impact that providers have on to key indicators of clinical effectiveness: symptom reduction and functional life improvement. Another important indicator – Lost Work Days – will become extremely important for persons in the workforce.

26. 10. Payment Reforms will be Linked to the Ability to Demonstrate Outcomes and Manage Costs • New funding mechanisms will be utilized to better fund services that manage total healthcare expenditures • Many Person-Centered Healthcare Homes will be funded with a 3-layer reimbursement mechanism Note: PPS = Prospective Payment System, the FQHC cost-based reimbursement system

27. 10. Payment Reforms will be Linked to the Ability to Demonstrate Outcomes and Manage Costs • Payment for inpatient care will bundle hospital and physician services • Bundled payments that only pay for part of Potentially Avoidable Complications (PACs) will penalize providers that have higher error rates and reward those with lower PAC rates • Bundled payments may include all costs in the 30 days post an inpatient stay, including any return to the hospital

28. Questions or Comments

29. The California IPI Report, Behavioral Health/Primary Care Integration and Person-Centered Healthcare Homes

30. California Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative Vision:Overall health and wellness is embraced as a shared community responsibility To achieve individual and population health and wellness (physical, mental, social/emotional/ developmental and spiritual health), healthcare services for the whole person (physical, mental and substance use healthcare) must be: seamlessly integrated planned for and provided through collaboration at every level of the healthcare system, as well as coordinated with the supportive capacities within each community

31. California Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative • Ten principles introduce the expectation that planning and implementation ensure that: • Each individual has a person-centered healthcare home, which provides mental health (MH) and substance use (SU) services in the primary care setting or primary care services in the MH/SU setting. • Each community has established a Collaborative Care Mental Health/Substance Use Continuum (the IPI Continuum). The IPI Continuum is a framework for service development that identifies population need across MH/SU levels of risk/complexity/acuity and assigns provider responsibilities within any given community for delivering those services. The community dialogue to establish the Continuum should result in mechanisms for stepped MH/SU healthcare back and forth across the Continuum, mechanisms to address the range of physical health risk/complexity/acuity needs of the population, and collaborative links between the integrated healthcare system and other systems, community services and resources. • Measurement is aligned to support the IPI Continuum, Quality Improvement and fidelity implementation of proven models as well as evaluation of emerging models, with accountability, transparency and measures matched to the levels of the Continuum.

32. California Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative

34. Model for Improving Primary Care

35. Substance Use Interventions in Primary Care • Center for Substance Abuse Treatment has sponsored Screening and Brief Intervention (SBI) programs in 17 states • Based on more than 30 controlled clinical trials that demonstrated the clinical efficacy and effectiveness of SBI • Screening and brief interventions for more than 424,000 people across inpatient, emergency department, primary and specialty care settings, including CHCs • Newly established series of Current Procedural Terminology (CPT) SBI codes provide a vehicle for billing SBI services (99408 and 99409) http://sbirt.samhsa.gov/about.htm • New National Council paper forthcoming that focuses on SU and Healthcare Homes

36. IMPACT Collaborative Care in Primary Care

37. The Person-Centered Healthcare Home: Q I and III • Incorporate the lessons of the IMPACT model, explicitly building into the medical home the care manager/ behavioral health consultant and consulting psychiatrist functions that have proven effective in the IMPACT model • DIAMOND project in MN—monthly case rate payments for covering these components in primary care practices, all major payors participating • All healthcare is local—working out the details of who does what, for what levels of MH/SU services (Intermountain model), has to engage local partnerships—the IPI Continuum is the guide for these dialogues

38. The Person-Centered Healthcare Home for People with SMI: Q II and IV For CBHOs envisioning a future role as person-centered healthcare homes, there are two pathways to follow: Providers who want to become full scope person-centered healthcare homes for people with SMI should look to the Cherokee model and seek to become full scope providers of primary care services, for a broad community population as well as for those receiving BH services Providers who want to partner with full scope primary care organizations to create person-centered healthcare homes for individuals with SMI should organize a parallel to the IMPACT primary care model, with collaborative care, care management, a designated PCP consultant, outcome measurement, and stepped care for primary care needs in BH settings

39. Assure regular screening and registry tracking/outcome measurement at the time of psychiatric visits for all BH consumers receiving psychotropic medications Locate medical nurse practitioners/PCPs in BH clinics—provide routine primary care services in the BH setting via staff out-stationed under the auspices of a full scope person-centered healthcare home BH organization hiring a nurse practitioner directly, without the backup of a skilled PCP and a full scope healthcare home cannot be described as providing a healthcare home, and is not a recommended pathway Identify a primary care supervising physician within the full scope healthcare home to provide consultation on complex health issues Assign nurse care managers to support individuals with elevated levels of glucose, lipids, blood pressure, and/or weight/BMI Use evidence based prevention practices that improve the health status of all individuals with chronic health conditions, adapting these practices for use in the BH system. Create wellness programs The Person-Centered Healthcare Home for People with SMI: Q II and IV

40. CBHOs Minimum Clinical Responsibility and Accountability (National Council for Community Behavioral Healthcare) If MH services include prescribing psychotropic medications, there are a set of accountabilities related to the whole health of the person: Assure regular screening and tracking at the time of psychiatric visits for all consumers receiving psychotropic medications Check glucose and lipid levels, blood pressure and weight/BMI Record and track changes, response to treatment and use the information to adjust treatment accordingly The individual and family history, baseline and longitudinal monitoring as recommended by the ADA/APA should be the standard of practice Identify the current PCP for each individual, and when none exists, assist the individual in finding a PCP and accessing care Establish specific methods for communication and treatment coordination with PCPs and assure that timely information is shared in both directions

41. Questions or Comments

42. Key Concepts in Developing a New California 1115 Waiver

43. Need to Align with Healthcare Reform • California Medi-Cal Waiver activities must be grounded in the healthcare reform legislation, including the previously mentioned hypotheses: • New designs must lead to Improved Quality and better management of Total Healthcare Expenditures • Effective mental health and substance use treatment are key components of managing Total Health Expenditures in the U.S. and bending the cost curve • This involves treating the healthcare needs of persons with serious mental illness and the behavioral healthcare needs (MH & SU) of all Americans • California’s public mental health, substance use and medical delivery systems, financing and management structures need to be better aligned and integrated into Organized Systems of Care to achieve these aims

44. Need to Align with 1115 Concept Paper • Focus on High Need/High Cost Enrollees • Ten percent of Medi-Cal beneficiaries account for 74 percent of the total program costs. Within this population, four percent account for 60 percent of the costs, according to a recent study by the Public Policy Institute of California. • Approximately 30 percent of Medi-Cal beneficiaries with disabilities have received treatment throughout the year for a mental health condition, while close to 9 percent are diagnosed with schizophrenia. These individuals are also far more costly than persons with disabilities who do not have a mental health condition. (Note: 49% prevalence rate for this group) • Promote Organized Delivery Systems of Care in 4 Phases • Seniors and persons with disabilities and children and families in rural counties • Children with special health care needs • Dual-eligible beneficiaries • Adults with severe mental illness Note: All four priority groups include persons with MH/SU conditions

45. “Raw Ingredients” of Public Sector Healthcare Reform in California There are eight existing “raw ingredients” that must be considered as healthcare reform stakeholders in California redesign current waivers and other structures to align with healthcare reform

46. Organizing the Raw Ingredients The raw ingredients need to be combined into integrated, organized systems of care to improve quality and bend the cost curve Note that as reform kicks in the number of indigent & uninsured residents and related funding will likely shift to Medi-Cal

47. The Organized Delivery System of Care Management Structure must address the 10 Core Health Plan Functions:

48. Three California Models to Consider • Acknowledging that all healthcare is local, we have identified three models of integration that build on existing designs in the California Counties • Single County Organized Health System Model (8 counties) • County Organized Health System + Private Health Plan Model (9 counties) • Small County Collaboration Model (31 counties) • All three models are organized aroundthe idea that each county would havean integrated design for the four Priority Populations (at a minimum)identified in the Waiver ConceptPaper, bringing current MediCal FFS populations into managed care and expanding coverage for indigent uninsured

49. Assumptions Embedded in All Models • Each Model assumes that: • Structures are put in place to support and ensure that the clinical activities mirror the healthcare reform goals of Improving Quality and managing Total Healthcare Expenditures • Substance use, mental health and primary care services will be clinically integrated and the financial and management structure will support clinical integration, versus hinder it (e.g., pay for same day services, etc.) • Services will be provided through an “Organized Delivery System of Care” (managed care) that operates within a quality improvement and performance measurement structure using the IPI Continuum as the framework for developing a collaborative delivery system that includes all levels of care • The Management Structure will seamlessly manage both Medicaid and non-Medicaid funds and services

50. Financing Ingredients • How will funds in other systems be integrated to support clinical integration? • We need a new paradigm—none of the old models (Carve-in or Carve-out) work for implementing bidirectional integrated care for the whole population • Lessons from the “field”: • Medical Home Pilots— case rate in addition to FFS, to cover prevention, care management of chronic medical conditions (why not build the BHC in PC role into the case rate?) • MN—financing the DIAMOND case rate (for BH in PC) out of the healthcare side (rather than the mental health side) believing that cost and quality improvements will be there • WA General Assistance project—explicit stepped care model that finances both Level 1 (primary care) and Level 2 (specialty) MH/SU benefits; dedicated financing for Levels 1 and 2; neither draw on dedicated mental health funding • Washtenaw Co, MI—global budget for Medicaid population; local consolidation of medical and behavioral health funding streams