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Public Mental Health the and BBA Issues and Strategies for Providers, PIHPs and States

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Title: Public Mental Health the and BBA Issues and Strategies for Providers, PIHPs and States


1
Public Mental Health the and BBA Issues and
Strategies for Providers, PIHPs and States
  • Dale Jarvis, CPA MCPP Healthcare Consulting
    National Council for Community Behavioral
    Healthcare
  • dale_at_mcpphc.com
  • (206) 613-3339

2
Chapter 1 Balanced Budget Act of 1997 and the
Public Mental Health System
3
Issue 1 CMS Oversight
  • The CMS Office of Inspector General has been
    taking a hard line against past CMS practices,
    finding them at fault for inadequate waiver
    oversight and approving state requests that are
    outside the letter of the law
  • The OIG is looking into issues in IA, KS, WA, UT,
    and CO and considering disallowances,
    de-categorizations and deferrals

4
Issue 1 CMS Oversight
  • CMS has stepped up their scrutiny of Medicaid
    contracts, waivers, state plan amendments, and
    state operations
  • Past approval from CMS is no guarantee that they
    wont come back and tell you the rules have
    changed

5
Issue 1 CMS Oversight Example
6
Issue 1 CMS Oversight Example
  • However, we recognize that when a capitated
    payment is made to an MCO or a PHP, the entity is
    required to meet contractual obligations to serve
    Medicaid beneficiaries within the money provided,
    and that except for limits that may be set on
    allowed profits (in for-profit entities), the MCO
    or PHP can use its savings as it wishes. In
    effect, it is no longer Medicaid money. In
    fact, should an MCO or PHP voluntarily choose to
    serve people who are not Medicaid eligible, it is
    free to do so. However, we believe it is not
    appropriate for the State Medicaid agency to
    require in its contracts with an MCO or PHP that
    savings from capitated payments be used to
    provide health services to individuals not
    otherwise eligible for Medicaid.
  • State Medicaid Director Letter 6/24/1998

7
Issue 1 CMS Oversight
  • CMS has unveiled a plan to begin prospectively
    reviewing state Medicaid budgets
  • A draft State Medicaid Director Letter from
    Dennis Smith noted
  • Over the last decade states have initiated a
    number of financing mechanisms to enhance the
    allowable Federal funding for their Medicaid
    programs. CMS and the OIG reviews of these
    programs have resulted in the identification of a
    number of potential disallowances of Federal
    Funds involving billions of dollars that have
    accumulated over the years… To address these long
    standing problems, CMS will implement a
    prospective financial management review process…

8
Issue 1 CMS Oversight
  • Soon afterward, the Administration made proposals
    in the Presidents Budget to institute new
    Medicaid program integrity activities saving the
    federal government 1.5 billion in FY2005 and
    23.5 billion over 10 years
  • Pushback by the National Governors Association
    resulted in a temporary pullback by Secretary
    Thompson, but…
  • Translation Expect CMS to play hardball in
    their oversight role

9
Issue 2 Actuarial Soundness
  • Under managed care, there is added flexibility to
    give clients what they need, even if it doesnt
    fit into a defined service code.
  • Cost savings from the Medicaid managed care plan
    can be used to provide additional mental health
    services we dont have to worry about giving
    money back if we dont spend it.
  • Recording and tracking every unit of services is
    not as important because were not begin paid fee
    for service.
  • We should be focusing more on managing to client
    outcomes than managing our unit cost and
    productivity levels.

10
Issue 2 Actuarial Soundness
  • The Final Rules include a very important change
    in the Federal financing of Medicaid managed care
    programs - the repeal of the Upper Payment Limit
    (UPL), replacing it with the requirement for
    States to set Actuarially Sound Capitation Rates.
  • Many States have considered the Upper Payment
    Limit a double edged sword.
  • On the one hand they were guaranteed 100 of
    the inflation-adjusted funding that they had
    received under the old, fee for service systems,
    even if they were able to achieve cost savings.
  • But States that had either done a good job
    managing costs in the old system, or had
    systematically underfunded the Medicaid programs
    were stuck at the old levels, regardless of the
    needs of the Medicaid population.

11
Issue 2 Actuarial Soundness
  • The New Math Medicaid Rates are based on
  • Counting the historical services that have been
    reported,
  • Multiplying them by a rate for each service, and
  • Adding/subtracting adjustments for inflation and
    expected changes in utilization
  • Rates must be based only on Medicaid services
  • If a provider provides services outside the state
    plan and theyre not one of the approved 1915(b)3
    alternative service, they wont be counted
  • Rates must only pay for services to Medicaid
    beneficiaries
  • If a plan uses any savings to serve persons who
    have lost their Medicaid coverage, they wont be
    counted (and they will be subject to recoupment
    in an audit)

12
Issue 2 Actuarial Soundness
  • A number of States have managed mental health
    care systems where PHPs/PIHPs have passed a
    portion of their capitated risk down to providers
    in the form of case rates or sub-capitation
    payments with the expectation that
  • Providers must meet the needs of the
    clients/populations for which they are
    responsible.
  • Providers are at risk for excess utilization and
    cost under case rates, plus penetration risk
    under sub-capitation.
  • Providers can reap the reward if savings were
    achieved.
  • These reimbursement methods inadvertently broke
    the link between recording/submitting services
    and being paid. As a result, there was a drop in
    reported state plan services and the inability to
    quantify how much was due to decreased clinical
    effort, and how much to service capture problems.

13
Issue 2 Actuarial Soundness
14
Issue 2 Actuarial Soundness
  • No Boren Amendment Rates do NOT have to be
    adequate to cover the costs of an efficiently run
    organization (Brenda Jackson, CMS/SAMHSA
    Conference, October 2004)
  • The BBA brought about the repeal of a provision
    of Medicaid law commonly known as the Boren
    Amendment, which stated that states Medicaid
    payments to hospitals, nursing facilities and
    ICF/MRs had to be sufficient to cover the cost of
    efficiently and economically operated
    facilities. Under the BBA the only requirement
    is that states must open their Medicaid
    ratesetting process to the public.
  • When the unit cost portion of the actuarial math
    problem is completed, theres no assurance that
    the actuaries will use figures that are relevant
    to the cost of doing business in the community
    mental health systems

15
Issue 2 Actuarial Soundness
  • Issue A number of actuarial firms are beginning
    to examine unit costs in publicly-funded mental
    health systems in a number of non-fee for
    service managed care states this issue had
    previously fallen below the radar screen.
  • Concern In States with PIHP designs that pay
    providers using methods other than Fee for
    Service, actual unit costs may be well above
    costs used in the actuarial studies and the
    provider community will not be able to respond
    quickly enough, which could result in loss of
    capacity and system instability.

16
Cost per Hour Example (actual data)
17
Issue 2 Actuarial Soundness
  • Under a system that uses actuarial approaches to
    set PIHP capitation rates, if a service has not
    been properly recorded at the provider agency,
    accurately transmitted to the PIHP, and then
    submitted and accepted by the State Mental Health
    Departments data system, the service did not
    occur. Regardless of the payment methods used
    by states to pay PIHPs, and PIHPs to pay
    providers, we have moved to what is essentially a
    fee for service system.

18
Issue 2 Actuarial Soundness
  • Yet to be answered questions include
  • How quickly will States and PIHPs respond to the
    new math?
  • Will the provider community train-up quickly
    enough to ensure that allowable services are
    properly captured and reported?
  • What are acceptable unit cost figures? Will
    urban, rural variations be taken into account?
    Will higher no-show rates that are often found
    with seriously mentally ill persons be taken into
    account?
  • Will the fidelity of evidence-based practices be
    negatively impacted by certain EBP services that
    may not be Medicaid-reimbursable? (portions of
    the Supported Employment and Family
    Psycho-Education SAMHSA EBPs)

19
Issue 3 Statewide Rates
  • States with county or regional-based PIHPs may
    have Medicaid PMPM rate models that could create
    a downward funding spiral
  • Example - Oregon Mental Health System
  • Round 1 The PriceWaterhouse Coopers actuarial
    study found that, on the average, PIHP PMPM rates
    were 12 higher than they could justify with
    their claims data
  • Rates were cut across the board to the PIHPs
  • PIHPs with higher utilization lost money PIHPs
    with lower utilization continued to be paid more
    than their utilization would justify.

20
Issue 3 Statewide Rates
  • Round 2 Preliminary results from the most recent
    PriceWaterhouse Coopers actuarial study found
    that, on the average, PIHP PMPM rates were 7.2
    higher than they could be justified from claims
    data
  • Rates will likely be cut across the board in this
    second round
  • Again, PIHPs with higher utilization will lose
    money PIHPs with lower utilization will continue
    to be paid more than their utilization would
    justify
  • Unless a targeted intervention is made this
    downward trend could continue

21
Issue 3 Statewide Rates
22
Issue 4 Access Planning
  • New Regulations for Ensuring Adequate Provider
    Capacity to Meet Enrollee Demand
  • Anticipated Medicaid enrollment
  • Expected utilization of services
  • The numbers and types of providers required
    (training, experience, and specialization)
  • The number not accepting new patients
  • The geographic location of providers and
    enrollees
  • The creates an opportunity to project what it
    would cost to meet the needs of the covered
    population it also raises the bar in relation to
    how most PIHPs plan
  • Recently CMS approved a new 5-county 1915(b)(c)
    combo waiver in North Carolina where we used this
    projections exercise to justify higher rates

23
Issue 4 Access Planning
24
Issue 5 Dual Standards for PIHPs
  • Savings in a world of Actuarially Sound Rates
  • If a PIHP has any money is left over at the end
    of the year, the savings must be put into a
    Community Reinvestment Fund, which must be
    earmarked for service delivery projects to
    Medicaid enrollees, to be spent in the following
    12 months.
  • If the PIHP is a governmental entity, savings
    equal payments minus expenses no provision for
    surpluses.
  • If a provider is related to the government-run
    PIHP (e.g. any overlap of board members), the
    provider organization will likely be considered a
    related party and any unexpended provider funds
    will also be called savings.

25
Issue 5 Dual Standards for PIHPs
  • CMS is interpreting Savings that need to go
    into the Community Reinvestment Fund in two
    different ways one for Public entities and one
    for Private entities
  • PIHPs
  • Public Entity Formula PMPM Revenue minus
    Expenses minus Risk Reserve (if any) equals
    Savings
  • Private Entity Formula PMPM Revenue minus
    Expenses minus Profit Allowance minus Risk
    Reserve (if any) equals Savings
  • Providers
  • Public Entity Formula (if related to the PIHP)
    Medicaid Payments minus Expenses equals Savings
  • All Others Not Applicable
  • Utah has recently built a 3 profit allowance
    into their PIHP rates. This would likely be
    prohibited if the PIHPs were Public Entities
    (versus nonprofit organizations)

26
Issue 6 Managed Care Risk
  • Potential disjoint between back to the future
    Fee For Service system and many managed care
    financing models
  • In the last ten years of managed care payors, in
    many instances, have shared financial risk with
    provider as a strategy for managing cost and
    giving provider more flexibility to provide the
    right care, in the right amount, at the right
    time
  • Risk is passed to the provider via the payment
    mechanism case rate, subcapitation (see next 2
    slides) or some variation
  • If providers dont properly manage the risk they
    will lose money
  • If providers do a good job managing the risk
    client outcomes can improve and the provider
    reaps a financial reward

27
Issue 6 Managed Care Risk
  • There are five levels of financial risk
  • The payment mechanism is the method by which risk
    is transferred from payor to provider
  • Payment mechanisms carry varying incentives for
    both payor and provider

28
Issue 6 Managed Care Risk
  • Cost Risk Services cost more per unit than
    planned
  • Individual Utilization Risk Individuals, on
    average, use more units of service than planned
  • Case Mix Utilization Risk The proportion of
    high-need cases is higher than planned
  • Penetration Risk More individuals from the
    covered population need services than planned

29
Issue 6 Managed Care Risk
  • One problem we occasionally run into is when a
    PIHP practices Pseudo Managed Care this is
    when a PIHP writes a contract with a provider
    where they pay the provider via a case rate or
    subcapitation, pushing risk down to the provider,
    but then allow the provider to only be paid for
    their costs (or less) this is know as a contract
    with downside risk and no upside reward
  • Under CMS current interpretation of the BBA,
    PIHPs are at risk to meet all of the behavioral
    health needs of the Medicaid population (no
    waiting lists, no refusal of medically necessary
    care) but, for all intents and purposes, have no
    upside reward if they provide efficient care
    they are going to get less money
  • Its only a matter of time before the unintended
    consequences of this new (old) model kick in

30
Issue 7 EQROs and PIHPs
  • An analysis of the EQRO Protocols show that they
    come from the world of NCQA-type quality
    improvement and are aimed at answering the
    following questions.
  • Do you have well-designed processes in place to
    manage the core MCO/PIHP activities?
  • Do you have a sufficient number of adequately
    experienced and trained staff to complete the
    work?
  • Are your processes properly documented?
  • Are the processes stable and predictable?
  • Are you actively engaged in continuous quality
    improvement efforts, including Process
    Improvement Projects (PIPs)?
  • Are you using data to support your improvement
    efforts?
  • Do you truly have a culture of measurement?

31
Issue 7 EQROs and PIHPs
  • The answer to the previous questions in a number
    of States, especially those with regional or
    county-based mental health PIHPs, is PROBABLY
    NOT.
  • Consider…
  • California has 58 counties and 57 Medicaid mental
    health PIHPs. 22 of the PIHPs have a total
    population (not Medicaid enrollees) of less than
    100,000 persons, and half of those have a total
    population under 30,000
  • Of the 80 mental health PIHPs on the West Coast
    (lower 48) at least ½ have PIHP staff of 4.0 FTEs
    or less and many have less than 2.0.

32
Issue 7 EQROs and PIHPs
  • Yet to be answered questions include
  • How many mental health PIHPs will receive
    passing grades on their EQRs?
  • How serious will the deficiencies be?
  • What kinds of corrective actions will be
    required, in what timeframe?
  • Is it possible for small regional or county-based
    mental health authorities to rise to the
    standards of a true NCQA-accredited health plan?
  • What expectations does CMS have for this first
    round of EQRs and how will they respond if there
    are a large number of poor results?
  • What will happen if performance does not
    appreciably improve in years 2 and 3 of the EQRs?

33
Chapter 2 Getting Re-Grounded in Managed Care…
  • (a prelude to looking at what states are doing to
    respond to the BBA)

34
Four Generations of Managed Care
  • Pre-Managed Care (post World War II with the
    growth of commercial, employer-funded health
    insurance)
  • Insurance companies do actuarial work and pay
    claims
  • Payors holds most of the risk
  • Pay providers on a fee for service basis
  • No concept of a provider network only licensure
  • Manage costs by keeping fees low and restricting
    eligibility or benefit package (little or no
    ability to manage utilization)

35
Four Generations of Managed Care
  • First Generation Managed Care (1971 Nixon
    strategy to develop Health Maintenance
    Organizations (HMOs)
  • Insurance companies take on new roles some
    providers become insurers (staff model HMOs)
  • Payor holds most of the risk
  • Pay providers on a fee for service basis
  • No concept of a provider network only licensure
  • Manage costs by tightly limiting access (who can
    get into care)

36
Four Generations of Managed Care
  • Second Generation Managed Behavioral Health
    Care (early 1980s with the implementation of
    managed behavioral healthcare carve-outs for
    employer plans)
  • New companies get into the managed care game
  • Payor holds most of the risk
  • Pay providers on a fee for service basis
  • Create provider network that agrees to play by
    the rules as a requirement for entry
  • Manage costs by requiring pre-authorization of
    all care, doling out services in small chunks
    and requiring frequent reauthorization
  • Use concurrent review for certain types of cases
    and retrospective review for sampling of cases to
    ensure that care is medically necessary

37
Four Generations of Managed Care
  • Third Generation Managed Behavioral Health Care
    (mid-1990s in public sector managed care
    demonstration projects)
  • Payor begins to share the risk
  • Pay providers on a fee for service, case rate
    basis, or subcapitation
  • Increase expectations of providers in the
    network match service demand with provider
    capacity
  • Replace most/all outpatient pre-authorization
    with agreed upon Level of Care Criteria,
    Assessment Tools to be used by all providers, and
    funding caps at the client and provider level
  • Use concurrent review for certain types of cases
    and retrospective review for sampling of cases to
    ensure the fidelity of leveling process and that
    care is medically necessary

38
Four Generations of Managed Care
  • Fourth Generation Managed Care
  • Continue to use Third Generation Managed Care
    strategies
  • Use Evidence-Based Practices to inform the Levels
    of Care, utilization parameters, and overall
    utilization and cost projections
  • Use Clinical Outcomes and other Performance
    Measures to measure success and reward (or not)
    providers

39
Chapter 3 State and PIHP Strategies
  • What states are (or should consider) doing to
    address the challenges embedded in the BBA

40
Strategy Area I Planning
  • Every state is somewhere on the following
    continuum
  • How and what you should do to respond to the BBA
    should be based on the quadrant you are in
  • Strategy 1 Complete a Self-Assessment of your
    State and PIHPs to determine what
    mismatches exist, if any, between your current
    design and the BBA

41
Strategy Area I Planning
  • States that are using a comprehensive approach to
    address the identified mismatches will be better
    served
  • Utahs PIHPs are working together and hoping to
    work more closely with the state
  • Oregon has not yet gotten organized as a group of
    PIHPs or at the state level
  • Washington has developed a plan but is having
    challenges implementing it
  • Strategy 2 State and PIHPs work collaboratively
    to develop a Strategic Action Plan that includes
    the High Impact Strategies Relevant to the State
  • The strategies in this presentation should be
    considered when developing your plan

42
Strategy Area I Planning
  • Washington State game plan

43
Strategy Area II System Management
  • Strategy 3 Ensure that the State and PIHPs Play
    an Active Role in Designing the Actuarial Study
    Methodology that will be used in your State
  • The state as the contracting entity has a
    responsibility to ensure that the actuarial study
    methodology is in alignment with the states
    public policy goals the actuary has a
    responsibility to ensure that the methodology is
    in compliance with CMS regulations
  • States working with their PIHPs can create a game
    plan whereby
  • The actuaries become a technical resource to the
    system
  • Proactive efforts are made to ensure that the
    data is complete, and where its not, data
    smoothing techniques are used
  • Unit costs are based on local community mental
    health realities
  • PriceWaterhouse Coopers in Oregon, Milliman USA
    in Washington, and Mercer in North Carolina have
    all been excellent resources and an extremely
    important part of the equation

44
Strategy Area II System Management
  • Strategy 4 Take a Proactive Approach to
    Determining the Unit Costs that will be used in
    the Actuarial Study
  • Determine the philosophy that the state will
    apply to costs
  • Example Keep the costs/fee schedules low to
    dissuade providers from running up the costs
    (e.g. pre-managed care strategy)
  • Example Payments should be sufficient to cover
    the cost of efficiently and economically
    operated facilities
  • Work with the actuaries to develop and complete a
    statewide Cost Study
  • Compile the results of the Cost Study and work
    with actuaries to ensure these figures are built
    into the PMPM rates
  • Example In Oregon PriceWaterhouse Coopers
    accepted the PIHP Cost Studies that concluded
    that mental health unit costs were approximately
    30 higher that the states usual and customary
    fee schedule

45
Strategy Area II System Management
  • Strategy 5 Re-Evaluate Your PIHP Allocation
    Methodology
  • Are you headed towards the Oregon experience?
  • Does the methodology need to be tweaked to
    address the new math problem?

46
Strategy Area II System Management
  • Strategy 6 Developing a Statewide Utilization
    and Cost Trend Model
  • Most states do not collect and report utilization
    and cost data on a timely basis and then project
    how the upcoming actuarial study will unfold
  • The alternative is to develop a Utilization and
    Cost Trend Model that will
  • Track data by PIHP, Medicaid and non-Medicaid
  • Segregate countable services from
    non-countable services
  • Use statistical modeling methods to trend the
    utilization through the end of the actuarial rate
    setting period
  • Update and analyze the model monthly
  • Identify corrective action measures before the
    actuarial rate setting period ends

47
Strategy Area II System Management
  • Strategy 6 Developing a Statewide Utilization
    and Cost Trend Model

48
Strategy Area II System Management
  • Strategy 7 Re-Evaluate Your Existing Provider
    Reimbursement Models
  • If you are one of the many states where, at the
    PIHP level, providers are paid on a
    sub-capitation, case rate, or similar non-fee for
    service model
  • Evaluate the potential risks from under reporting
    and the gaps between payments and claims
  • Examine alternative payment models, including the
    many versions of fee for service
  • Determine the cost-benefit of moving to a new
    reimbursement model
  • Identify the potential transition plans that
    would facilitate such a move

49
Strategy Area II System Management
  • Strategy 7 Re-Evaluate Your Existing Provider
    Reimbursement Models

50
Strategy Area II System Management
  • Strategy 8 Data Quality Initiative
  • Develop a statewide strategy, to be executed at
    the PIHP level, to improve the completeness,
    accuracy and timeliness of encounter data
  • Several states have taken a proactive approach to
    develop
  • Clinician Service Coding User Guide
  • Comprehensive Training Curriculum
  • Infrastructure to Disseminate the Training to
    EVERY CLINICIAN IN THE PUBLIC MENTAL HEALTH
    SYSTEM
  • Monitoring Process to evaluate the success (or
    not) of the Data Quality Initiative
  • Corrective Action Strategies if data quality
    problems still exist

51
Strategy Area II System Management
  • Strategy 8 Data Quality Initiative
  • Example Training Curriculum

52
Strategy Area III Public Policy
  • Build the Public Policy Case for Protecting and
    Expanding State Funding
  • Strategy 9 Determine the Gap between Need and
    Available Funding, using Available Data
  • SAMHSAs prevalence methodologies for Adults and
    Children
  • NASMHPD/NRIs 50 States Cost Comparison Data
  • Combination of these two data sources
  • In 2000 Washington State was able to demonstrate
    a 216 million shortfall in the public mental
    health system the report was instrumental in
    preventing budget cuts during times of
    substantial state budget shortfalls

53
Strategy Area III Public Policy
  • Build the Public Policy Case for Protecting and
    Expanding State Funding
  • Strategy 9 Determine the Gap between Need and
    Available Funding, using Available Data

54
Strategy Area III Public Policy
  • Build the Public Policy Case for Protecting and
    Expanding State Funding
  • Strategy 10 Create a Statewide Clinical Redesign
    Grounded in Evidence-Based Practices and Utilize
    the Actuarial Utilization Adjustment Step
  • The Final Rules Ratesetting Checklist describes
    the standard actuarial procedure related to
    adjustments of historical utilization data based
    on the States mental health system design
  • Under the Final Rules States have the opportunity
    to translate a mental health system redesign into
    a financial model that projects the expected
    utilization and cost for the system

55
Strategy Area III Public Policy
  • Strategy 10 Create a Statewide Clinical Redesign
    Grounded in Evidence-Based Practices and Utilize
    the Actuarial Utilization Adjustment Step
  • Example Washington State Proposal
  • Develop a Revised Clinical Design for the State
    public mental health system based on desired
    shifts in service approaches, including
    Evidence-Based Practices (EBPs) for adults and
    children.
  • Create an Implementation Workplan for desired
    service adjustments across the State, projecting
    the level of penetration for these practices over
    a multi-year period.
  • Research and project Utilization and Cost Changes
    that will occur through the use of new clinical
    model and practices and the discontinuation of
    other services that have not demonstrated their
    effectiveness.
  • Build these Utilization and Cost Changes into the
    Utilization Adjustment steps of the subsequent
    Actuarial Models.

56
Strategy Area III Public Policy
  • Strategy 10 Create a Statewide Clinical Redesign
    Grounded in Evidence-Based Practices and Utilize
    the Actuarial Utilization Adjustment Step

57
Strategy Area III Public Policy
  • Build the Public Policy Case for Protecting and
    Expanding State Funding
  • Strategy 11 Expand Coverage for Non-Medicaid
    SMI/SED Clients
  • Maximize Presumptive Eligibility efforts through
    work with your states Medicaid eligibility unit,
    drawing on best practices efforts in New York
    City, Seattle, and other communities
  • Consider a targeted 1115 waiver for SMI, SED not
    currently eligible for Medicaid, layered on top
    of the existing 1915 waiver (e.g. Patrick
    Barries Michigan analysis)
  • Achieving budget neutrality through a
    reallocation of resources that come out of the
    clinical redesign

58
Strategy Area III Public Policy
  • Strategy 11 Expand Coverage for Non-Medicaid
    SMI/SED Clients

59
Strategy Area III Public Policy
  • Build the Public Policy Case for Protecting and
    Expanding State Funding
  • Strategy 12 Watch Californias Proposition 63

60
Dale A. Jarvis, CPA
  • Dale Jarvis is a Managing Consultant at MCPP
    Healthcare Consulting, a Seattle-based consulting
    firm. Mr. Jarvis helps health and behavioral
    health organizations and system managers develop
    and install practical financial planning,
    analysis and information systems.
  • He has contributed articles to publications and
    is a co-author of two books, The Primary Care
    Performance Management System and How to Thrive
    in Managed Behavioral Healthcare.
  • In recent years he has worked with over 60 PIHPs
    and provider organizations in several states
    addressing behavioral health financing and
    technology-related issues.
  • Dale can be reached at dale_at_mcpphc.com and (206)
    613-3339. MCPP Healthcare Consulting is on the
    web at www.mcpphealthcare.com.
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