Behavioral Health Integration

1. Behavioral Health Integration NAMI Maryland July 31,2012

2. Public Mental Health System (PMHS) • In 1997, 1115 waiver implemented in Maryland, mental health services were carved out into the managed fee-for-service system. Many services that had previously been grant funded became funded on a fee-for-service basis. • Nearly all non-emergency service require pre-authorization. Services are authorized and claims processed and paid through an Administrative Services Organization (ASO). Current ASO-Value Options. • Eligibility data from Medicaid feeds daily into the ASO data system. Used to determine eligibility and authorization of services. • Majority of the services are delivered under the Fee-for-Service (FFS) system. • Evidence Based Practice-Assertive Community Treatment, Supported Employment

3. Maryland’s Outcome Measurement System (OMS) • The Outcome Measurement System (OMS), implemented statewide in FY 2007, was developed to collect information on several life domains (including symptoms, functioning, living situation, employment, school performance, alcohol and substance use, legal system involvement, and somatic health) from individuals, ages 6-64, who are receiving mental health services in outpatient settings from Maryland’s fee-for-service system. • OMS information, gathered directly through interviews between the clinician and consumer, is collected at the beginning of treatment and approximately every six months thereafter while an individual is receiving treatment.  • Value Options, in collaboration with MHA and the Univ. of Md. SEC, developed an OMS datamart that has the ability to perform analysis and reports available to MHA, providers, CSAs, and the general public. • The OMS system provides Point-in-Time as well as Change-over-Time data.Datamart Link: http://maryland.valueoptions.com/services/OMS_Welcome.html

5. Good and Modern System • We have a good system that can be better. • The challenge is: to move to a financial system that includes risk sharing and facilitates the integration of care for mental health, substance use and physical health care without losing the current strengths of the PMHS.

6. Integration of Care We know that integration is important. We know that: 30% of all individuals with a mental health/substance use disorder may have 3 chronic conditions; that Roughly 1/3 of all cigarette smokers have an mental health/substance use disorder; that The cost of treating common diseases higher when a patient has untreated behavioral health problems: Hypertension – 2x the cost Coronary heart disease – 3x the cost Diabetes – 4x the cost.

7. Integration of Care • The concept of integration of Care is not new. • Medicine has been sensitive to the importance of mind/body interactions for centuries. Many of us were trained in psychosomatic medicine and the BioPsychoSocial model of care. • However, the carve out decision in the 1990’s was made with full knowledge of the importance of integrated care. The decision was made based on the desire to protect services. There was a fear Managed Care would focus on profits and destroy the public mental health system. • A great deal has been learned over the last 15 years. We are now ready to move to a system that prioritizes and facilitates integrated care while protecting needed funding and services.

8. Behavioral Health Integration • During 2011, DHMH retained a consultant to evaluate the provision of behavioral health services. The report from the consultant noted that Maryland’s system has many strengths. However, the consultant also noted the lack of alignment between mental health, substance use and physical health services. • This project builds on that consultant’s report. As directed by Secretary Sharfstein, the Deputy Secretary for Health Care Financing, Chuck Milligan, will make a recommendation on the best model to better align mental health, substance use and physical health. The Department is seeking broad public input to inform this recommendation. The report will be completed by September 30, 2012,

9.   Behavioral Health Integration Criteria to Select Model Best ensures delivery of the right service, in the right place, at the right time, by the right practitioner Best ensures positive health outcomes in behavioral health and somatic care using measures that are timely and transparent Best ensures preventive care, including early identification and intervention Best ensures care across an individual’s lifespan Best ensures positive consumer engagement Best aligns with treatment for chronic conditions Best ensures the delivery of culturally and linguistically competent services that are evidence-based and informed by practice-based evidence Best ensures that the system is adaptable over time, as other payment and delivery system reforms occur, without loss in value or outcomes Best ensures program integrity and cost-effectiveness Best ensures administrative efficiencies at state, local, plan, provider, and consumer/family levels Best ensures seamless transitions as service needs change, and as program eligibility changes

10. Model 1: Protected Carve-In (recommended in consultant report) • Medicaid-financed behavioral health benefits would be managed by Medicaid managed care organizations (MCOs) through a “protected carve‐in”. The MCOs would be responsible for managing a comprehensive benefit package of general medical and behavioral services. MCOs would receive a separate, dedicated behavioral health capitation payment that only could be spent on behavioral health treatment and recovery supports. Any savings related to behavioral health services would be re‐directed to additional, innovative behavioral health benefits. This model would protect funds spent on behavioral health treatment but would allow the MCOs to have flexibility in how they structured care coordination, utilization management, etc. Specific behavioral health performance standards would allow the State to evaluate access, adequacy of the provider network, treatment quality, and outcomes.

11. Model 2: Risk-Based Service Carve-Out • Medicaid-financed specialty behavioral health benefits would be managed through a risk-based contract with one or more Behavioral Health Organizations (BHO). Using a competitive selection process, Medicaid would contract with one or more BHO(s) that would bear insurance and/or performance risk. Contractual conditions would be aligned with those of the Medicaid MCOs; performance standards would be robust; and performance risk would be shared with MCOs for continued implementation of health homes for persons with behavioral health conditions, as well as health homes for persons with chronic medical conditions and for improvement in health outcomes for persons enrolled in health homes. The services delivered through the BHO(s) would be specialty behavioral health services. MCOs would continue to provide specified behavioral health care typically associated with primary care providers.

12. Model 3: Risk-Based Population Carve-Out • As in Model 1, all Medicaid-financed behavioral health benefits and general medical benefits would be delivered under a comprehensive risk-based arrangement. • In this model, however, Medicaid would competitively select one or more specialty health plan(s) to manage the comprehensive benefit package for individuals with serious behavioral health disorders. That is, enrollment in the specialty health plan would be determined by whether the individual has a specified behavioral health diagnosis, such as SPMI. If such a diagnosis is present, the person would be enrolled in a specialty health plan, which would be required to deliver the full array of behavioral health and medical benefits. If such a diagnosis is not present, the person would be enrolled in a traditional MCO to receive his/her full array of behavioral health and general medical benefits.

13. Linkage Workgroup • Purpose: To make a recommendation on those factors that should be present to promote "integration." For example, should there be a shared electronic health record among all providers? What is needed for “collaborative” care? “integrated”care?

14. State/Local and Non-Medicaid Workgroup Purpose: • To make a recommendation on what services/financing should be left outside a “Medicaid” integrated care model to accommodate non-Medicaid eligible populations, or non-Medicaid-eligible services. • This Workgroup will also make a recommendation on the roles that state and local government should perform depending on which services/financing are left outside of the Medicaid financing model, as well as how to support and interface with selected model.

15. Data/EvaluationWorkgroup. Purpose: • To determine what data is available and relevant to the recommendation of the model, • To make a recommendation on potential measures to evaluate any selected model.

16. Chronic Health Home Workgroup Purpose: • To make a recommendation on a new “Health Home” service under the Affordable Care Act. • To make a recommendation on how the new service could be developed to support any integration model. • For example, this workgroup will help define the service; the population eligible for the service; and the provider qualifications to deliver the service.

17. Summary: We are good but aiming for Better! We must develop the best shared risk model for Integrating care, controlling cost, protecting needed services and ensuring best practices. We must develop capacity to provide a high quality workforce . We must take advantage of technology (ie expand telemedicine). We must improve quality of data and the ability to measure outcomes. We must facilitate better linkages with health providers and other partners (Corrections, Juvenile Services etc). We must provide non-medical services (e.g., housing, employment) necessary for recovery. We must define the role for Core Service Agencies and Health departments in the new health care system.