Title: The New Rules of the Game An indepth look at the Balanced Budget Act of 1997 and how to respond to i
1The New Rules of the GameAn in-depth look at
the Balanced Budget Act of 1997 and how to
respond to its challenges
- Dale Jarvis, CPAMCPP Healthcare Consulting
National Council for Community Behavioral
Healthcare - dale_at_mcpphc.com
- (206) 613-3339
2Agenda
3Chapter 1 Additional BBA Issues
4Issue 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
5Issue 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
6Issue 1 CMS Oversight Example
7Issue 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
8Issue 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
9Issue 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
10Issue 2 Unit Costs
- 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
11Issue 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.
12Issue 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
13Issue 3 Statewide Rates
14Issue 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
15Issue 4 Access Planning
16Issue 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)
17Issue 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
18Issue 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
19Issue 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
20Issue 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
21Questions, Comments?
22Chapter 2 Getting Re-Grounded in Managed Care
- (a prelude to looking at what states are doing to
respond to the BBA)
23Four 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)
24Four 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)
25Four 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
26Four 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
27Four 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
28Chapter 3 State and PIHP Strategies
- What states are (or should consider) doing to
address the challenges embedded in the BBA
29Strategy 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 determinewhat
mismatchesexist, if any, betweenyour current
designand the BBA
30Strategy 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
31Strategy Area I Planning
- Washington State game plan
32Strategy 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
33Strategy 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
34Strategy 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?
35Strategy 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
36Strategy Area II System Management
- Strategy 6 Developing a Statewide Utilization
and Cost Trend Model
37Strategy 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
38Strategy Area II System Management
- Strategy 7 Re-Evaluate Your Existing Provider
Reimbursement Models
39Strategy 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
40Strategy Area II System Management
- Strategy 8 Data Quality Initiative
- Example Training Curriculum
41Strategy 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
42Strategy 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
43Strategy 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
44Strategy 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.
45Strategy Area III Public Policy
- Strategy 10 Create a Statewide Clinical Redesign
Grounded in Evidence-Based Practices and Utilize
the Actuarial Utilization Adjustment Step
46Strategy 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
47Strategy Area III Public Policy
- Strategy 11 Expand Coverage for Non-Medicaid
SMI/SED Clients
48Strategy Area III Public Policy
- Build the Public Policy Case for Protecting and
Expanding State Funding - Strategy 12 Watch Californias Proposition 63
49Questions, Comments?
50Small Group Setup
- Question 1 What are the top 3 threats that the
BBA brings to the Michigan Community Behavioral
Health System? - Question 2 What are the top 3 Strategies that
should be considered to support and improve the
current system? - Process
- Choose a group facilitator and recorder
- Use the Issues and Strategies from this session
and the morning Plenary plus your knowledge of
the Michigan system - Break your time into 4 segments
- 5 minutes to brainstorm Question 1 Threats
- 5 minutes to select Top 3
- 5 minutes to brainstorm Question 2 Strategies
- 5 minutes to select Top 3
51Small Group Reports Discussion
52Dale 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.