Title: Brave New World: Ideas for Reinventing How Public Behavioral Health should be Organized and Financed
1Brave New World Ideas for Reinventing How Public
Behavioral Health should be Organized and Financed
- Dale Jarvis, CPA
- NCCBH Consultant
- MCPP Healthcare Consulting
- dale_at_mcpp.net
- www.mcpphealthcare.com
2Session Overview
- The public behavioral health system in the United
States is fragmented, disorganized and
under-funded. This has led to funding inequities
between states, a near-inability to leverage
change at a national level, and unrealistic
expectations at the provider organization and
individual service provider level. In this
session we will explore an emerging set of ideas
for transforming the public behavioral health
system at the region, state and federal level and
the implications for the Michigan system. This
will include discussion of - The essential ingredients of change and whats
missing in public behavioral health - An Institute of Medicine-inspired change model
for reinventing the system - How P4P (Pay for Performance) can support
positive changes in the system - How the federal government and the State of
Michigan can support these changes - How this material is relevant to your
organization and what you can do now to prepare
for a kinder and gentler future
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5An Institute of Medicine-Inspired Change Model
6Institute of Medicine www.iom.org
- Id like to explore a change model presented in
two important books from the IOM. - Crossing the Quality Chasm A New Health System
for the 21st Century (2001), is an important work
that put forth a strategy for improving health
care overall. However, health care for mental and
substance-use conditions has a number of
distinctive characteristics, such as the greater
use of coercion into treatment, separate care
delivery systems, a less developed quality
measurement infrastructure, and a differently
structured marketplace. - Improving the Quality of Health Care for Mental
and Substance-Use Conditions Quality Chasm
Series (2005), builds on the first book,
examining the differences between general health
care and mental and substance-use conditions.
This book addresses strategies pertaining to
health care for both mental and substance-use
conditions and the essential role that mental and
substance use care plays in improving overall
health and health care including the actions
required of clinicians health care
organizations health plans purchasers and
state, local, and federal governments.
7IOMs Quality Chasm Series
- Arguably the weakest chapter of Crossing the
Quality Chasm is chapter 8, Aligning Payment
Policies with Quality Improvement. - The Mental and Substance-Use Conditions edition,
Chapter 8, Using Marketplace Incentives to
Leverage Needed Change provides an even weaker
analysis of behavioral health financing and what
to do about it. - This, combined with the 50 states, 50 sets of
rules reality for public behavioral health,
creates a significant gap between current reality
and where we need to go. - Lets try and do something about that
8IOM Strategy for Reinventing the System
- The 2001 IOM report described the components of
an effective care system, including a supportive
payment and regulatory environment, supporting
organizations whose main purpose in life is to,
support high performing patient-centered teams
that achieve the six IOM aims for improvement
(e.g. Outcomes).
9IOM Strategy for Reinventing the System
- The Six IOM aims for improvement can be
described as providing care that is - Safe avoiding injuries to patients from the care
that is intended to help them. - Effective providing services based on scientific
knowledge to all who could benefit, and
refraining from providing services to those not
likely to benefit. - Patient-centered providing care that is
respectful of and responsive to
individualpatient preferences, needs, and
values, and ensuring that patient values guide
all clinical decisions. - Timely reducing waits and sometimes harmful
delays for both those who receive and those who
give care. - Efficient avoiding waste, including waste of
equipment, supplies, ideas, and energy. - Equitable providing care that does not vary in
quality because of personal characteristics such
as gender, ethnicity, geographic location, and
socioeconomic status.
10IOM Strategy for Reinventing the System
- The IOM has identified six redesign imperatives
that must be addressed inside the service
delivery system in order to have care systems
that are able to achieve the six aims.
11IOM Strategy for Reinventing the System
- Addressing these challenges requires a
fundamental re-engineering of how most community
mental health centers are organized and managed
and an even more fundamental shift in how CMHCs
are financed. - Id like to use the our time today to focus on
creating a supportive payment and regulatory
environment, making the assumption that this is a
prerequisite for supporting improvements in the
overall behavioral healthcare system.
12Chapter 3 Creating a Supportive Payment
Regulatory Environment
13Talking with Actuaries
- If you were it sit down with any of the big 3
actuarial firms and have a conversation about how
much of what type of general health care service
needs to be provided to a population in a
specific state, region or county, they would pull
up all kinds of exciting data. This would
include detail down to the subspecialty level,
presented as Relative Value Units (RVU) per 1,000
enrollees along with payments per RVU for the
different payor types. The following table
illustrates what you might see.
14Talking with Actuaries
These figures come out of vast healthcare
databases that have been compiled over several
decades and have been refined to the point that
they can be used to develop accurate predictions
of healthcare utilization and cost. Note the
differences in demand across the three payor
categories.
15Talking with Actuaries
- If you change the conversation and start asking
similar questions about public behavioral health
utilization and cost you will have a very
different experience. - The actuary may begin a similar conversation
about things like penetration rates of 3 and
2.5 visits per user per year, which you will
quickly realize is about their commercial mental
health database and they have little or no data
on public sector mental health. - If the actuary does have public sector numbers to
pull up, they will contain large, unexplainable
variation across states for similar populations
(Medicaid and indigent), and the actuary will
either throw up their hands in frustration or
note that the variation simply reflects reality
utilization and cost in different systems are
driven by dramatic differences in policy and
funding. - This has contributed to the huge variation in
spending that is illustrated in the following
slide.
16Status of a Supportive Payment Regulatory
Environment (per capital mental health spending
in the U.S.)
Source NASMHPD 2004 Report
17Why the Variation?
- This experience with the actuary can be traced to
the fact that the public mental health system is
really 50 state level systems funded by state and
local general funds, federal block grant funds
and the federal/state Medicaid program
(historically driven by state level policy within
federal parameters). States have very different
financial and structural arrangements, and
service modalities and definitions, for the
purchase and delivery of public mental health
services. - Within many states are regional authorities that
have significant variation in the coverage rules,
services provided, payment methods, and more,
even though this is generally not looked upon
kindly by CMS. On the West Coast alone
California has 57 plans, Oregon 10 and Washington
13. - Roughly half of the states have federal waivers
for managed care of their Medicaid mental health
programs. Where the state has structured the
Medicaid program into a carve-out, much of the
focus has been on reduction in cost, particularly
for inpatient services. Assumptions regarding
utilization and cost have often been built from
commercial models or the general Medicaid
population rather than based on serving the
public mental health target population, generally
identified as adults who are seriously and
persistently mentally ill (SPMI) or
children/youth who are seriously emotionally
disturbed (SED).
18So What?
- The problem is that, with all of this
variability, the public mental health system
does not have the kind of cost and utilization
information that has been collected over the
years by health plans regarding the delivery of
services to a defined population. And the
available mental health data represent a
historical snapshot of a system that often lacks
access to appropriate services, has services that
may not be as effective as newly emerging
evidence-based practices (EBPs), and services
that have been fragmented, with cost shifting to
and from other payors. - This makes it extremely difficult for anyone to
answer the question What would it cost to
provide quality services in the public mental
health system? - To do this we need to return to our actuary
friends and their vast healthcare databases,
because this issue has already been addressed in
the general healthcare system.
19How Healthcare Does it
- When a new medication, medical device or clinical
approach comes onto the scene, it generally
starts out as an experimental approach and isnt
approved for coverage by health plans. Generally
led by Medicare, there is a process through which
the research is reviewed and health plans adopt
new practices for coverage and payment. While
some practices are spelled out in benefit
packages, specification of evolving improvements
may also only occur at the level of the claims
adjudication process. This cycle of formal
approval for specification in the claims coding
and adjudication process automatically ensures
that the next cycle of RVUs reflect the evolving
practice. - For example, in the last fifteen years there have
been many improvements in cardiac care. The
angiogram (enabling pictures of blockages in
coronary arteries) was succeeded by the balloon
angioplasty (threading a balloon into the artery
and expanding it to open a blockage), which was
improved by placements of stents (a scaffolding
to hold the artery open at the point of blockage)
to the current use of drug-eluting stents (stents
with drugs that discourage plaque from sticking).
As these practices emerged, they have been
approved, incorporated into practice, and their
utilization and cost incorporated into RVUs and
DRGs.
20How Healthcare Does it
- However, what the health care system has also
discovered is that coverage of evidence-based
practices alone does not ensure that they are
always consistently used. For example, Medicare
is tracking whether hospitals are implementing
what research shows makes a big difference in
outcomes for patients arriving with a heart
attack.--provision of aspirin and a beta blocker.
- The first report in the New England Journal of
Medicine a year ago showed variability among
states in delivering the appropriate therapy
(from 97 of the time to 85 of the time) and
among hospitals (from 100 of the time to 50 of
the time). While assuring payment is a necessary
condition to the delivery of research based care,
it may not be sufficient. - We also know from the health care system that
some procedures, while covered, may be subject to
over-utilization. We should be mindful from these
examples of what infrastructure will be required
over time to grapple with these same issues in
mental health care.
21Public Mental Healths Dilemma
- Public mental health system stakeholders are
caught in the conundrum of being unable to use
historical actuarial data because, unlike general
healthcare, the information rarely describes a
system that has been using modern practices to
meet the true needs of the population. Indeed,
somewhere in the 50 states table shown above is a
yet-to-be-drawn line that separates states into
two groups those that may have enough money to
meet basic mental healthcare needs, and those
that do not. - For those states that may have sufficient
funding, there hasnt been adequate analysis to
determine whether the states are utilizing their
resources in the most effective manner, nor an
analysis of what services should be ramped down
as recovery-oriented, evidence-based services are
ramped up. The following charts illustrate the
concern.
22Public Mental Healths Dilemma
The pie charts describe expenditures for four
urban Medicaid mental health plans in Washington
State. Acute care includes crisis services,
state hospital and community inpatient.
Non-acute care includes outpatient, residential
and other direct services.
- Even though the Medicaid capitation rates are
somewhat similar in the four counties, Pierce and
Spokane are having an extremely difficult time
maintaining persons with serious mental disorders
in the community because the amount of funding
going to acute care results in an under-funding
the non-acute care system. Do any of us think
that we should we use the data from those two
counties to set the RVUs for psychiatric
inpatient and outpatient care?
23Stop Whining and Do Something
This diagram lists eight steps in a process for
transforming the public behavioral health system
at the region, state and federal level. Note The
last icon represents the fact that this process
will require multiple change cycles.
24Population-Based Planning
- A data-driven approach to behavioral health
planning is quite consistent with Actuarial
Science and includes answering the following
questions - What are the target populations, what is the
projected prevalence of mental illness in those
groups, and how many people ought to be
receiving service in a given year? How do these
projections compare with the numbers of people
served in the last three years? - Based on research and experience in this and
other states, what services do clients need and
how much of each type of service do they need?
How do these projections compare with the service
utilization over the course of the last three
years? - What service capacity does the mental health
system have in place to meet these needs? How
well does capacity match with demand? What
excesses and gaps exist by clinician type and
service type? - What is the cost of meeting the projected demand
(e.g. how much money should the state be
spending on public mental health)? How do these
projections compare with actual expenditures over
the last three years? - These question add detail to the first three
steps in the process. Some examples follow.
25How Many People
Mental Health prevalence for a 3-County Region in
rural Washington State.
26How Many People
Substance Abuse Prevalence Forecast for a
mid-sized California County.
27How Many People
Key Point We must adopt and begin using a
standardized method for projecting how many
persons require publicly funded behavioral health
services in a given year.
Gap Analysis for a 5-County Region in Northwest
Washington State.
28How Much Service
- More and more systems are using the LOCUS to
develop Level of Care Systems. It is a national
tool, with adult and child/youth versions,
developed by the American Association of
Community Psychiatrists to guide assessment,
level of care placement decisions, continued stay
criteria, and quality monitoring. It also allows
system planners to understand how many low,
medium and high need clients are in the system. - Until the public behavioral health system adopts
methods for identifying the acuity of persons
with serious mental disorders, There will be no
basis for projecting how much service should be
provided. - In many ways this is not unlike the DRG system
used in hospitals and the Johns Hopkins
University ACG Case-Mix System now being use in
the medical outpatient world.
Key Point We must adopt and begin using a
standardized Level of Care System with every
individual that is served in the public
behavioral health system.
29How Much Service
The mental health system in Portland Oregon
completed a clinical design, identified what
services should be available to persons with
SMI/SED as well as other Medicaid enrollees
needing mental health treatment, and projected
demand based on historical use, research, and
projected utilization at each level. This slide
projects use for non-SMI/SED persons.
30How Much Service
This slide projects need for persons with
SMI/SED in Portland Oregon.
31How Much Service
This slide projects substance abuse service need
for the mid-sized California County.
32Chapter 4 Financial Design Considerations
33Financing the New System
- The current set of options for behavioral
healthcare financing in the U.S. are stuck in one
of the alternative universes know as managed-care
or pre-managed care. - Although there continue to be debates about the
pros and cons of sub-capitation, case rates and
fee-for-service - CMS has weighed in, telling us that, for all
intents and purposes, they now set Medicaid
capitation rates by counting and pricing the
number of Medicaid services to Medicaid
enrollees. - The rest of the healthcare world has all but
abandoned non-fee-for-service payment mechanisms
at the provider level. - And budget-based approaches to financing care
have too few accountability mechanisms unless
they are made to look and feel like fee-for
service. - What is missing from the behavioral health
financing discussion are well-articulated new
approaches.
34Healthcare Financing
- Current payment methods do not adequately
encourage or support the provision of quality
health care All payments methods affect behavior
and quality. For example, fee-for-service
payment methods raise questions about potential
overuse of services. On the other hand,
capitation and per case payment methods raise
questions about potential underuse Too little
attention has been paid to the careful analysis
and alignment of payment incentives with quality
improvement. - (Crossing the Quality Chasm, page 17.)
35Mental Health/Substance Use Treatment Financing
- Recommendation 8-2. State government procurement
processes should be reoriented to give the most
weight to the quality of care to be provided by
vendors. - A substantial proportion of public M/SU treatment
services are purchased through government grants
to local providers. These providers are
frequently private nonprofit organizations that
serve the population of a particular
geographically defined catchment area, and are
typically well-established organizations having
long-standing relationships with state and local
governments. Services are most commonly purchased
through a system of grants. The grants are
awarded subject to the providers meeting
licensing standards and achieving specified
service levels. Funding is frequently set at
levels that result in patient queues - indicating
excess demand for services. There are few
quality-of-care standards forming a basis for
accountability for these organizations. Moreover,
pressures from excess demand create incentives
for local providers to expand the volume of
treatment even if doing so results in reduced
quality. - Recommendation 8-3. Government and private
purchasers should use M/SU health care quality
measures (including measures of the coordination
of health care for mental, substance-use, and
general health conditions) in procurement and
accountability processes. - (Improving the Quality of Health Care for Mental
and Substance-Use Conditions Quality Chasm
Series pages 316-317.)
36Healthcare Financing
- In light of these concerns, several important
projects have been underway in healthcare that
have direct applicability to behavioral
healthcare financing. - Two fall under the rubric of Pay for Performance
(P4P) one in the California commercial
insurance system the other in the Medicare
system. - Under these systems, providers are paid through
the existing payment system and are offered
bonuses for performance. - P4P bonuses are often related to quality and
efficiency. - Quality is currently being measured through a set
of process measures, which will be described
shortly. - Efficiency (a euphemism for cost) is measured
through comparisons with peers. - Both sets of measures require risk adjustment so
that Provider X, who has very ill patients, is
properly compared with Provider Y, who has very
healthy patients. - This approach has the potential in behavioral
health to combine a fee-for-service reimbursement
system with a P4P system where bonuses are paid
for reducing cost and improving quality. - Lets look at they two systems and then talk about
a BH financing model.
37Californias P4P Project
- The California P4P project hit the streets in
2002, which was a testing year. Plans included - Aetna (California)
- Blue Cross of California
- Blue Shield of California
- CIGNA HealthCare of California
- Health Net (California)
- PacifiCare (California)
- Totaling 7 million HMO enrollees, 215 medical
groups and 45,000 doctors
38Californias P4P Project
- Vision
- The achievement of breakthrough improvement in
healthcare performance. - Central Goal
- The overall goal of Pay for Performance (P4P) is
to significantly improve physician group
performance in quality of health care and patient
experience through public recognition and
financial reward. - Core Principles
- Collaboration (with purchasers, health plans,
physician groups and consumers) - Measurement (clinical quality, patient
experience, and infrastructure to support patient
care) - Reward (financial incentives tied to performance
results significant and sustained to justify
investment in system reengineering) - Accountability (including a public scorecard of
physician group performance for consumers and
providers in order to make informed choices. - (Source IHAs February 2006 Five Year Report)
39Californias P4P Project
- P4P First Year - Measurement Set
- Clinical Quality (50 weighting)
- Preventive care breast cancer screening,
cervical cancer screening, childhood
immunizations - Chronic care asthma (medication), diabetes
(testing), heart disease (cholesterol management) - Patient Experience (40 weighting)
- Communication with doctor timely access to care
specialty care and overall ratings of care - Investment and Adoption of IT to support patient
care (10 weighting) - Point of care and population management (disease
registries, electronic medical records, physician
and provider reminders)
40Californias P4P Project
- Clinical Measures can be captured from health
plan information systems. About ½ are preventive
measures and the other ½ are chronic care
management measures. These are process measures
versus outcome measures e.g. cervical and
breast cancer screening has been proven to reduce
cost and mortality related to these diseases
they are not being scored on actually reducing
cervical or breast cancer.
41Californias P4P Project
- Sample Report Card for Los Angeles County,
http//iha.ncqa.org/reportcard/Frames.aspx?cid38
42Californias P4P Project
- Patient Experience Measures are captured through
the Consumer Assessment Survey (CAS). This slide
lists the measures and provides a snapshot of the
doctor-patient communication items. Payment
formulas vary by plan, but are generally based on
scores (e.g. 100 for being at the 75th
percentile or higher, 50 for being between 50th
and 74th percentile).
43Californias P4P Project
- Sample Report Card for San Diego County,
Communicating with Patients.
44Californias P4P Project
- Provider Groups are rewarded if they invest in
specific technologies that have been determined
to improve the quality of care. This information
is based on self-reporting.
45Californias P4P Project
- Adoption of IT systems for purposes such as
building patient registries for at-risk or
chronically ill patients and use of electronic
decision support systems at the point of care
offer potential improvements in the quality of
care. The physician groups who received full
credit on the IT measures had average clinical
scores that were nine percentage points higher
than physician groups who showed no evidence of
IT adoption. - (Source IHAs February 2006 Five Year Report,
Page 17)
46Californias P4P Project
- Core Principle
- Reward
- Financial incentives tied to performance
results. - Significant and sustained to justify investment
in system reengineering.
47Medicare Inpatient P4P
- A Medicare pay-for-performance pilot program that
rewards hospitals based on quality has "steadily
improved the quality of patient care," according
to the latest results from the three-year
program, the New York Times reports (Abelson, New
York Times, 1/25). The demonstration project,
which launched in October 2003, includes about
260 hospitals in 38 states (Kaiser Daily Health
Policy Report, 6/22/06). Under the program,
hospitals can earn bonuses if they rank among the
top 20 in providing specified treatments in at
least one of five areas of patient care joint
replacement, coronary artery bypass graft, heart
attack, heart failure and pneumonia. According to
the data, participating hospitals overall
experienced nearly 1,300 fewer deaths in treating
heart attack patients, and they generally have
scored higher on quality measures than other U.S.
hospitals. CMS officials on Friday will announce
performance bonuses of 8.7 million to 115
hospitals that were the top performers based on
30 quality measures in the second year of the
project. Premier, a not-for-profit hospital
alliance, is managing the program. CMS and
Premier have begun discussions about whether to
extend the project as "Congress has also asked
Medicare to look into developing a new payment
system that would put more emphasis on rewarding
the best care," the Times reports. (Medical News
Today, 1/29/07) - Medicares pilot program has used a design that
rewards the top 20 regardless of how well the
other 80 are doing. Hospital payments should
focus on encouraging hospitals to make
significant strides in improving care, and should
not be based on rankings. The hospitals say they
are now clustered so closely at the top that it
is increasingly hard to qualify for extra
payments, even if their results continue to
improve. (NY Times, 1/25/07)
48Medicare Inpatient P4P
- Why is this important?
- The heart is a muscle that gets oxygen through
blood vessels. Sometimes blood clots can block
these blood vessels, and the heart cant get
enough oxygen. This can cause a heart attack.
Chewing an aspirin as soon as symptoms of a heart
attack begin may help reduce the severity of the
attack. This chart shows the percent of heart
attack patients who were given (or took) aspirin
within 24 hours of arrival at the hospital.
49Medicare Outpatient P4P
- A new pay-for-performance experiment in four
states may be a precursor of Congress's intent to
implement such a quality-control program
throughout the Medicare system. - The Medicare program will launch a three-year
pilot pay-for-performance, or P4P, program next
year to encourage physicians who treat
chronically ill patients to adhere to specific
quality-control guidelines. - The demonstration project will compensate
physicians based on the quality of care they
provide to Medicare beneficiaries with chronic
conditions in 800 small- or medium-sized
practices in Arkansas, California, Massachusetts,
and Utah. - During the first year, physicians will be paid
for reporting data on quality measures. In
subsequent years, the program will offer
physicians annual performance-based bonuses of
10,000 per clinician and up to 50,000 per
medical practice. - The program will continue to pay physician groups
on a fee-for-service basis, but participating
physicians will submit annual data on up to 26
"quality measures" on the care of patients with
diabetes, congestive heart failure, and coronary
artery disease, as well as the provision of
preventive health services, such as immunizations
and cancer screenings, to high-risk patients with
a range of chronic diseases. Mental illnesses are
not among the conditions in the program,
according to the Centers for Medicare and
Medicaid Services (CMS), which administers
Medicare.
50Chapter 5 Putting the Pieces Together - A
Proposal for a new Design for Financing Public
Behavioral Healthcare
51Behavioral Health Financing Model
- Each state, region and local setting has a unique
mix of financial challenges that must be
understood in order to match their behavioral
health clinical design to currently available and
potential funding sources. - The National Council is beginning to develop a
set of behavioral health financing
recommendations that are relevant to most states
and regions. - This chapter presents a preliminary look at these
recommendations.
52Behavioral Health Financing Model
- Recommendation 1 The Substance Abuse Mental
Health Services Administration (SAMHSA) and the
Centers for Medicare and Medicaid Services (CMS)
should institute a joint project to supporta
redesign of the public behavioral health system,
modeled on the Institute of Medicines Change
Model. This work should include - Updating the final methodology for estimating
the prevalence of serious mental illness and
serious emotional disturbance to include a
component for estimating the demand for public
behavioral health services. - Developing a set of cost models to accompany the
evidence-based practice work that has already
been completed. These cost models should include
3 components the cost of implementing each EBP,
the annual cost of providing these services, and
the potential cost offsets. - Developing a set of regulatory changes that would
better facilitate blended funding of behavioral
health services including Medicaid, Medicare,
SAMHSA and other federal programs. - Analyzing the different healthcare reimbursement
methods in relation to their alignment (or not)
with current CMS regulations. - Recommending Pay for Performance mechanisms that
could be piloted by state Medicaid programs.
53Behavioral Health Financing Model
- Recommendation 2 Every State, using the
resources provided in Recommendation 1, should
project the cost of meeting the behavioral health
needs of citizens that require publicly funded
behavioral health care. This should include
analysis of - What are the target populations, what is the
projected prevalence of mental illness in those
groups, and how many people ought to be
receiving service in a given year? - Based on research and experience in this and
other states, what services do clients need and
how much of each type of service do they need?
- What is the cost of meeting the projected demand?
- We understand that in the absence of standardized
acuity-based level of care systems and limited
work in the costing of evidence-based practices,
States will have to estimate projected
utilization levels and cost.
54Behavioral Health Financing Model
- Recommendation 3 Every State should complete a
gap analysis between available resources (funding
and workforce) and the projected demand for
publicly funded behavioral health services. - This is the same requirement CMS makes for
Medicaid health plans under the BBA - 42 CFR 438.207(b) Documentation of adequate
capacity and services The contract must require
that the entity submit documentation to the
State to demonstrate, in a format specified by
the State, that it - (1) Offers an appropriate range of preventive,
primary care and specialty services that is
adequate for the anticipated number of enrollees
for the service area. - (2) Maintains a network of providers that is
sufficient in number, mix, and geographic
distribution to meet the needs of the anticipated
number of enrollees in the service area. - This analysis should by stratified by geographic
region, age group, and payor sources (e.g.
Medicaid, Medicare, Dual Eligibles,
Indigent/Uninsured).
55Behavioral Health Financing Model
- Recommendation 4 Every State should complete an
assessment of the use of evidence-based and
promising practices in the public behavioral
health system, including what it will cost to
close any gaps that exist. - The purpose of this recommendation is to enhance
the quality of the cost recommendation, which
requires evaluating - The deployment of evidence-based services that
are being provided with fidelity. - The deployment of evidence-based services that
are being provided below fidelity. - Populations and service areas that would benefit
from the use of evidence-based services provided
with fidelity. - Changes in the type and quantity of services that
would be needed to improve the effectiveness of
the system. - The projected costs of making the changes
described above. - The cost offsets that would be realized.
56Behavioral Health Financing Model
- Recommendation 5 Every State should complete an
assessment of the infrastructure gaps that hinder
the provision of effective and efficient care. - This assessment should include an analysis of
gaps and costs to fill those gaps related to - Redesigning/re-engineering care processes
- Effective use of information technologies
- Workforce development including knowledge and
skills management - Developing of effective teams
- Coordinating care across patient conditions,
services and settings over time - Use of performance and outcome measurement for
continuous quality improvement and accountability - (You many note that these are the 6 redesign
imperatives from Crossing the Quality Chasm.)
57Behavioral Health Financing Model
- Recommendation 6 Every State should complete an
assessment of the reimbursement systems used in
the state and how they should be changed to
comply with federal laws/regulations and support
effective and efficient care. - Core elements of an effective reimbursement
system that should be considered include - Capacity-based funding for services that require
fire department like coverage such as crisis
programs. - Fee-for-service type methods where funding
follows clients based on client need, paired with
an acuity-based level of care system. - Pay for Performance mechanisms to support
reengineering efforts and the development of
needed infrastructure that will increase the
quality of care (and is not covered through other
payment mechanisms). - Pay for Performance mechanisms to reward provider
organizations that are able to reduce the cost of
care through improved quality (and would
otherwise result in reduced revenue).
58Behavioral Health Financing Model
- Recommendation 7 Each State should translate
their work in Recommendations 2 6 into a long
range Behavioral Health Financing Plan with a
multi-year implementation strategy that aligns
with elements 4 8 of the Change Model. The 50
state plans should be compiled and use to support
state and federal legislation for improving the
system while closing funding gaps that exist.
59Behavioral Health Financing Model
- Recommendation 8 SAMHSA should work with the
States to develop a clearinghouse of Behavioral
Health Financing Plans including - State-level demand and cost forecasting models.
- Funding and workforce gap analyses.
- Strategies for expanding the use of
evidence-based practices. - Further refinements in the cost analysis of
evidence-based practices. - Infrastructure gap assessments.
- Reimbursement designs.
- Pay for Performance strategies.
60Next Steps
- My next steps include working with the National
Council for Community Behavioral Health to refine
these recommendations and move them forward in
the public policy arena. - I would invite each of you ponder this talk and
email me with comments about the relevance of
these ideas for your State and suggestions for
what should be added and changed in these
materials. (dale_at_mcpp.net)
61Questions and Answers