Mental Health: Network Design

1
Mental Health Network Design
PROPOSAL FOR DISCUSSION ONLY
Draft 10/11/2004

• Celeste Putnam
• Deputy Secretary
• Substance Abuse and Mental Health

Jeb Bush Governor
Lucy Hadi Interim Secretary
2
Current Public Mental Health System
AHCA Medicaid Payment for Services
DCF/ADM Contract for Services

Monitoring
Data

Provider
Provider
Provider
Provider
Provider
Provider
Provider
Provider
Provider
Provider

• DCF/ADM contract enables providers to enroll as
  Medicaid mental health providers. Each provider
  can serve clients moving in and out of
  eligibility.
• This results in congruent provider system and but
  there are no managing entities to organize into
  single system of care. The department must
  manage 590 individual contracts.
• Providers report performance and outcome data to
  the department on both Medicaid and department
  funded clients.
• The department monitors agencies that are both
  Medicaid and department providers.

3
Separate AHCA - DCF Systemwithout Networks
Mental Health by Districts
AHCA/Single Entity by Area
Prepaid Behavioral Health Plan
Provider
Provider
Provider
Provider
Provider
Provider
Provider
Provider
Provider
Provider

• Non-AHCA/DCF
  Services
• Housing Coalitions ?Medical (non-Medicaid
  eligible
• Vocational Rehabilitation ?Generic Support
• Education

• Multiple administrative costs.
• Inability to share in workforce development.
• Fragmented services.
• Very difficult for consumers/child/family to
  navigate.
• Loss of safety net concept due to fragmentation.
• Potential cost shifting.
• Decreased capacity for achieving uniform clinical
  policies and installation of best practices.
• Potential loss of uniform client level data
  reporting and related quality improvement
  initiatives.

4
Separate AHCA - DCF Systemwith Networks

• HMOs

AHCA/Medicaid Area
DCF/ADM District
Prepaid Behavioral Health Plan
Managing Entity
CBC
Provider
Provider
Provider
Provider
Provider
Provider

• Non-AHCA/DCF Services
• Housing Coalitions ?Medical (non-Medicaid
  eligible
• Vocational Rehabilitation ?Generic Support
• Education

• Introduces managing entities but results in
  potential system fragmentation among multiple
  managing entitiessystem is still hard to
  navigate for clients.
• Higher costs related to multiple small risk pools
  and multiple managing entities less for
  services.
• Loss of safety net concept due to fragmentation.
• Potential for increased cost shifting between
  entities.
• Decreased capacity for achieving uniform clinical
  policies and installation of best practices.
• Potential loss of uniform client level data
  reporting and related quality improvement
  initiatives.

5
AHCA DCF Integrated System
AHCA/Medicaid Area

Management Contract

DCF District
HMOs
Compliance/TA/Service Coordination

Single Behavioral Health Managing Entity
Provider
Provider
Provider
Provider

• Non-AHCA/DCF
  Services
• Housing Coalitions ?Medical (non-Medicaid
  eligible
• Vocational Rehabilitation ?Generic Support
• Education

• AHCA contracts with DCF to manage an integrated
  system of behavioral health care for DCF clients
  and Medipass recipients. (70 of adults with
  severe and persistent mental illness and children
  with severe emotional disturbance are enrolled in
  Medipass.) Federal Medicaid administrative match
  funds could underwrite this added management
  capacity.
• DCF and AHCA would have complementary funding
  contracts with the same single managing entity in
  each area. ADM district offices would organize
  around AHCA regions.
• The combined ADM/AHCA system will remain the
  safety net for public sector clients. Clients
  receive same services regardless of payer.
• This managing entity would create a seamless
  system of care for high need clients moving in
  and out of Medicaid eligibility. An Active
  consumer panel guides and informs the managing
  entity.

6
Benefits of an Integrated System

• The Use of a single managing entity enables the
  Department to contract for all publicly funded
  and mental health services.
• Contracting with the same managing entity
  promotes
• QUALITY
• INCREASED ACCESS
• COST-EFFECTIVENESS

7
Quality

• Increases Clinical Standards - Standard
  expectations for providers about credentialing,
  training, use of clinical protocols, serve to
  raise the clinical bar and enhance access,
  quality, treatment and improve satisfaction by
  recipients and their families.
• Promotes Implementation of Evidence-Based and
  Promising Practices Common standards for all
  network providers means the Department can
  require network providers to implement current
  best practices (Example District 1
  implementation of FALGO medication algorithm and
  the Minkoff Co-Occurring model).
• Increases Promotion of Recovery-Oriented Services
  With all network providers operating under a
  common set of values and principles that drive
  treatment decisions, comes an expansion of
  cost-effective, community-based recovery services
  and supports that promote community living and
  recovery of individuals with serious mental
  illnesses.
• Strengthens Recipient and Family Involvement
  Common values and principles that support
  recipient and family member involvement in
  decision making in all aspects of the service
  system leads to greater acceptance of policy
  decisions and reduces complaints. The managing
  entitys role in interfacing with recipients and
  their families on issues results in swifter
  resolution and promotes an opportunity for
  recipient and family education on key areas such
  as Advanced Directives.

8
Quality

• Enhances Integration of Care The use of a
  single managing entity provides the framework for
  service integration. Integration of health care,
  mental health is enhanced with uniform
  eligibility criteria and a more comprehensive
  array of services and supports.
• Increases Partnerships The Department can
  specify the terms of agreements with other system
  partners, such as law enforcement, jails and the
  Court system. These partners have come to expect
  certain services and supports for persons they
  refer to the publicly-funded mental health
  system.
• Increases Quality of Services The refinement of
  common values and principles allows for the
  development of a network management plan for
  quality improvement and quality assurance
  consistent with the Departments goals and
  objectives, rather than simple adherence to
  accrediting body standards that may not reflect
  Departmental priorities. The network QA/QI plan
  provides a mechanism for structured clinical
  monitoring that is ongoing, and enables the
  Department to trouble-shoot clinical issues for
  more immediate response.
• Provides for Comprehensive Data and Data Analysis
  The Department would be able to require that
  data for all publicly funded services be reported
  to the Departments One Family Mental Health data
  system. This will allow for the comprehensive
  and continuous analysis of data for timelier,
  less costly, more proactive system improvements
  to better meet recipients needs.

9
Equal Access

• Creates Equal Access The use of consistent
  access standards for all recipients regardless of
  funding source enhances access to public mental
  health services and supports (Citation USF
  FMHI 2003 Draft Report).
• Enhances Uniformity The development of standard
  expectations among providers promotes uniform
  treatment of recipients.
• Ensures Compliance with Legislative Intent
  State legislators that sponsored Senate Bill 1258
  (394.9084, F.S.) and Senate Bill 2404, envisioned
  an integrated behavioral health services delivery
  system. The use of a single managing entity
  overseeing a single network of mental health
  providers is consistent with legislative
  direction.
• Emphasizes Department Priorities Uniform
  requirements help the Department ensure that
  individuals served by the public mental health
  system that are considered priority populations
  (children in the Departments custody for
  example) are provided services regardless of
  funding mechanism. Recipients most at risk are
  those who need complex forms of care children
  and adolescents, elders, persons with dual
  diagnoses and those involved in the criminal
  justice system (Citation Center for Health Care
  Strategies Working Paper, August 2002).

10
Cost-effectiveness

• Reduces Costs to the State The uniform
  application of managed care principles that
  promote access, quality of treatment and are
  cost-effective result in a more cost-effective
  system. Contracting with the same managing
  entity can lower overall administrative costs due
  to economies of scale. (Citation USF FMHI
  Evaluation of District 1).
• Reduces Administrative Costs for the Network
  Providers Contracting with the same managing
  entity allows for more flexibility in the
  financing of services. This allows the managing
  entity to develop compatible financial, clinical
  and program structures for both Medicaid and SAMH
  funding, resulting in a reduction in associated
  administrative costs.
• Comprehensive data for all publicly-funded
  recipients will allow the Department to more
  accurately determine potential cost-shifting to
  the Department. It will also enable the
  Department to analyze the utilization of
  recipients receiving high cost services, such as
  state mental health treatment facilities and
  crisis stabilization units (CSUs).
• Effective use of limited staff Allows staff to
  focus on effective and meaningful activities.

11
What about Substance Abuse?

• Should Substance Abuse be part of an Integrated
  System?
• The Medicaid Single Entity does not include
  Substance Abuse.
• Network selection would have been made without
  Substance Abuse criteria.
• Leaving Substance Abuse outside of network
  creates greater fragmentation.
• Should Substance Abuse have a separate network
  linked with Mental Health?
• A significant percent of persons have
  co-occurring disorders.
• Medicaid will eventually capitate Substance
  Abuse.
• Substance Abuse will be a smaller entity separate
  from larger more established networks.