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CA 1115 Waiver Expanding SUD Continuum

Medicaid expansion and the requirements for mental health and addiction parity have created improved insurance coverage for treatment of substance use disorders.  Various initiatives are underway to improve capacity of the substance abuse service system, including developing the service array and the ability of providers to deliver services within the requirements of Medicaid and private insurers.

In August 2015, the California Department of Health Care Services announced CMS approval of its 1115 waiver amendment for a continuum of care for substance use disorder treatment under the Drug Medi-Cal Organized Delivery System (DMC-ODS).  The DMC-ODS will be implemented in 5 regional phases, and is designed to increase local accountability and oversight, create utilization controls to improve care and efficient use of resources, while implementing evidence based practice and strong care coordination.  The continuum of care is modeled after the ASAM criteria, and the waiver will permit Medicaid reimbursement for qualified residential services that otherwise would not be covered due to the IMD exclusion.

California’s efforts to improve treatment for SUDs under its Medicaid program may offer innovative options for other states and insurers over the next few years.  For more information:  http://www.dhcs.ca.gov/provgovpart/Pages/Drug-Medi-Cal-Organized-Delivery-System.aspx

 

Impact of Physical/Behavioral Healthcare Integration

The American Psychiatric Association (APA) recently released a report prepared for them by Milliman, Inc., entitled, “Economic Impact of Integrated Medical-Behavioral Healthcare: Implications for Psychiatry”.  The analysis provided in the report summarizes by payor (Commercial, Medicare, Medicaid) the elevated levels of MedicalSymbolhealthcare costs related to beneficiaries who have chronic medical and behavioral comorbidities. Based on the outcomes of several recent integration projects, the actuaries estimate the portion of the elevated healthcare costs that can be controlled through such programs. The report is interesting with its detailed, claims based analysis of costs, its methodology for conducting the analysis, and for producing per member per cost data by payor for enrollees with no behavioral health services, those with non-SPMI behavioral health, those with SPMI, and those with substance use disorders.

Themes from Innovative Complex Care Management Programs

solutionIn many regions across the country, robust “super-utilizer” programs providing intensive outpatient care management to high-need, high-cost patients are beginning to emerge. The term “super-utilizer” describes individuals whose complex physical, behavioral, and social needs are not well met through the current fragmented health care system. As a result, these individuals often bounce from emergency department to emergency department, from inpatient admission to readmission or institutionalization—all costly, chaotic, and ineffective ways to provide care and improve patient outcomes.

The Center for Health Care Strategies (CHCS), in partnership with the National Governors Association, hosted a Super-Utilizer Summit on February 11 and 12, 2013. The Summit brought together leaders from super-utilizer programs across the country, states, the Centers for Medicare & Medicaid Services, the Robert Wood Johnson Foundation (RWJF) Aligning Forces for Quality (AF4Q) alliances, health plans, and other key stakeholders to share strategies for changing how our health care system interacts with these high-need, high-cost patients.

This report presents the Summit’s common themes and key recommendations for building better systems of care for high utilizers. The appendices also include materials related to existing complex care management programs that can be educational resources for states and policy-makers considering ways to implement, spread, and sustain such programs.SuperUtilizersSummitReport 2013

Emerging Models of Integrated Care Coordination

As behavioral health providers strategize on where they can fit in healthcare reform, I see care coordination as an obvious role where many providers could thrive. Central to healthcare reform is improved coordination and navigation of the complex healthcare delivery system to ensure whole-person, whole-life prevention, early intervention, supports, and care. Some of the models for care coordination read like good old fashion social work, while other more intensive models sound like modified ACT teams.

Sure, to really excel at this “new” care coordination, behavioral health providers will need to makes some changes but bottom line, this work should be in the wheelhouse of behavioral health core competencies. Likely behavioral health provider development needs include:
~ Shift of staff resources from “therapies” to care coordination
~ Robust training, development, and supervision in medical management
~ Effective partnering with primary care organizations
~ State of the art care coordination data management system

The Institute for Healthcare Innovations published a white paper in 2011 IHICareCoordinationModelWhitePaper2011 which provides a great overview of successful care coordination models.

NM 1115 Waiver Re-Submitted

The New Mexico Human Service Department re-submitted its Medicaid 1115 Waiver on August 17, 2012 reflecting changes based on the recently completed series of public comment opportunities. The waiver continues to plan for an expected “go live” of January 1, 2014. Largely consistent with the Centennial Care Concept Paper released early this year, the waiver represents an ambitious model of integration of the management of physical, behavioral, and long term services. The HSD request for proposals to select the vendors to manage the integrated program is anticipated to be released around September 1, 2012.

Summary of Health Home SPAs (Section 2703)

By the end of June, CMS had approved 8 health home SPAs (Section 2703) in 6 states–IA, MO, NY, NC, OR and RI. While all include persons with serious mental illness, the other provisions related to enrollment, provider types and reimbursement structures vary widely across states. The link below provides an excellent summary of each state’s waiver(s). As implementation of these health home models progress, it will be fascinating to watch the operational details and client impact develop in each state.

New Mexico Medicaid Modernization

New Mexico has released a Concept Paper describing “Centennial Care”, the framework for ambitious changes to Medicaid. Built on the values of health care integration, it seeks to combine up to 12 existing Medicaid waivers into one 1115 Demonstration Waiver. In addition it would integrate long term care, physical care, and behavioral healthcare, all of which would be administered and managed by 3-5 managed care organizations. Building upon their experience with a single statewide managed care entity for the management of Medicaid and non-Medicaid behavioral health services, New Mexico has set forth a vision that while integrating behavioral health, affords specific protections to ensure that any savings from behavioral health are not shifted elsewhere. The state intends to release their draft 1115 waiver application soon in order to stay on track with an expected “go live” date of October, 2013.

IL Plan for Williams v Quinn Pending Court Approval

The implementation plan and tasks/timeline for resolution of the Illinois class action suit, Williams v Quinn has been submitted to the court and is pending approval.  Both are available for public review.  On September 30, 2010 the consent decree representing agreement to offer community living arrangements to over 4300 individuals with mental illnesses currently residing in Illinois institutes for mental disease (IMDs) was approved. Over 5 years, Illinois will offer transition to permanent supported housing or similar community settings for the class members.

Illinois ACT/CST Rate Review Report

In preparation for transitioning Williams class members into community services, Parker Dennison was asked to assess whether the current rates for team-based services, ACT and CST, are adequate to support expansion of capacity for these services.  The findings can be found in the complete report available to the public.  ACT CST Summary Rept 6-30-11Final

Proposed HCBS Waiver Rules Released

On April 15, 2011, the federal Centers for Medicare and Medicaid (CMS) released proposed rules with the stated purpose of increasing states’ flexibility for use of the 1915(c) Medicaid Waiver.  There are three major provisions:

Option to Combine Disability Groups into One Waiver

The rule would allow multiple disability groups (aged or disabled, developmentally disabled, and mentally ill) into one waiver.  Currently, rules require a separate waiver for each disability group.

Clarification of Allowed HCBS Settings

The proposed rule expressly defines settings where HCBS services may be provided as well as adds a provision whereby the Secretary has full discretion to determine if a setting has “qualities of an institution”.  Under the proposed rule, the HCBS setting definition requirements include:

  1. Must be integrated into the community
  2. Must not be located in building that also provides institutional or custodial care
  3. Must not be located on the grounds or immediately adjacent to a public institution
  4. Must not be a housing complex designed expressly around an individual’s diagnosis or disability as determined by the Secretary
  5. Must not have qualities of an institution as determined by the Secretary including:
    1. Regimental meal and/or sleeping times
    2. Limitations on visitors
    3. Lack of privacy
    4. Other attributes that limit the individual’s ability to engage freely in the community

Person-Centered Planning Required

Previously optional, the proposed rule would require the state to adopt a person-centered planning model.  Under the proposed rule, the person-centered planning requirements include:

  1. Must be based on a person-centered functional assessment with defined requirements including identifying the individual’s strengths, preferences, needs (clinical and supports), and the individual’s desired outcomes
  2. Directed by the individual and may include a representative(s) freely chosen by the individual to assist and include a team of their own choosing
  3. Include paid and non-paid services and supports
  4. Result in a service and support plan in the most integrated community setting
  5. May result in a personal service budget which the individual may direct.

Comments on these proposed rules will be taken through June 14, 2011.  Complete copy of the proposed rule–HCBSProposedRule04152011.

 

 

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