Evaluation Results of the Prepaid Mental Health Demonstration: Year 7 Areas 1 and 6 Briefing for the

1
Evaluation Results of the Prepaid Mental Health
Demonstration Year 7 - Areas 1 and 6Briefing
for the Substance Abuse and Mental Health
CorporationAugust 4, 2004

• David L. Shern, Ph.D.
• and the Evaluation Team
• Louis de la Parte Florida Mental Health Institute

2
Framing Evaluation Questions

• What are the implementation issues related to
  systems redesign and expansion?
• What is the impact of managed care on Medicaid
  enrollees
• Access to care?
• Health and mental health status?
• Costs of care?

3
Financial Risk Arrangements
4
Integrated Sub-Studies

• Implementation Analysis
• Review of Contracts
• Surveys of Key Informants and Stakeholders
• Administrative Data
• Medicaid Enrollment and FFS Claims
• Managed Care Encounter Data
• Pharmacy Claims Data
• Global Functioning Measures for Service Users
• Adults with SMI Intensive Interview Study
• Mental Health Status and Satisfaction Data
• Social Cost Analysis
• Medicaid General Population Mail Survey

5
Description of the Provider Networks

• Area 6
• HMOs primarily use the 5 main Community Mental
  Health Centers in the area
• All Fee-For-Service in the beginning
• Shifted to capitation over time, but some
• Fee-For-Service still present
• PMHP uses the same 5 Community Mental Health
  Centers - stable structure over time
• Use risk adjusted capitation to Community Mental
  Health Centers

6

Area 6 Funding Streams as of 4/04
Agency for Health Care Administration
SA, SIPP, FACT, BHOS, STFC, Comprehens.
Assessment
FHP/VO
AmG
HE
STAY
UHC
MG
MHC
WBH
UBH
Northside
Medicaid enrollees not eligible for managed care
PR
WH
AssociateProv.
Community Mental Health Centers
Providers
Other Providers
Solid line Capitation Dotted line Fee for
service
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Provider Networks

• Area 1
• The PMHP and HMO have different provider networks
• Fee-For-Service for HMO Relationships
• Capitation for PMHP

8

Area 1 Funding Streams as of 6/04
Agency for Health Care Administration
SA, SIPP, FACT, BHOS, STFC, Comprehens.
Assessment
ABH LVC
HE
WCBH
BW
Medicaid enrollees not eligible for managed care
COPE
Providers (excluding LV)
Associate Providers
Providers
Solid line Capitation Dotted line
Fee-for-service
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What Have We Learned?
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The HMO Business Arrangements Have been
Accompanied by Greater Instability and Complexity
in Organizational Arrangements
11

Organizational Structure Funding Streams as of
1/00
Agency for Health Care Administration
St.A.
FL 1st
PHP
HE
STAY
PCA
UHC
ALP
FHP
MG
Value Options
MHC
MAG
WEL
APS
Horizon
UBH
CBC
Northside
MHC (CMHC)
BHM
PR
MHC (CMHC)
WH
AssociateProv.
Community Mental Health Centers Other Providers
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Area 6 Funding Streams as of 3/02
Agency for Health Care Administration
FHP/VO
ST.A
FL 1st
PHP
HE
STAY
UHC
MG
MHC
UBH
CBC
HZ
Northside
PR
CMHC
WH
AssociateProv.
Community Mental Health Centers
Other Providers
Black FFS Blue Outpatient capped only
Red Outpatient Inpatient capped Dotted line
Risk Sharing
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Figure 6. Area 6 Funding Streams as of 4/04
Agency for Health Care Administration
SA, SIPP, FACT, BHOS, STFC, Comprehens.
Assessment
FHP/VO
AmG
HE
STAY
UHC
MG
MHC
WBH
UBH
Northside
Medicaid enrollees not eligible for managed care
PR
WH
AssociateProv.
Community Mental Health Centers
Providers
Other Providers
Solid line Capitation Dotted line Fee for
service
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Implementation of Managed Care Has Not Resulted
in Improved Access to Services
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Average 6-Month Penetration for Carve-Out
Services Areas 1, 2, and 4
Case Mix Adjusted
16
Average Annual Penetration for Carve-Out Services
Only Areas 6, 4 and 7
Case Mix Adjusted
17
People with Schizophrenia enrolled in HMOs,
which are at risk for pharmaceutical expenses,
are less likely to receive atypical antipsychotic
medications
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Atypical Penetration Areas 4 6 Adult
Schizophrenia Diagnosis Only
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• Enrollees are Receiving Fewer Services or Less
  Intensive Services in the Managed Care Conditions
• HMO Enrollees Receive Fewer Services than Persons
  in the PMHP

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PMPM Standard Costs by Category Areas 1, 2 4
(Case Mix Adjusted)
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PMPM Standard Costs by Category Areas 6, 4 and
7 (Case Mix Adjusted)
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Reduced Intensity of Services has Generally Not
Been Associated with Poorer Outcomes for Managed
Care EnrolleesYouth in Area 1 Require Further
Study to Explain Poor Outcomes
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Change in Predicted GAF Score Over Time For Ages
21-64 in Areas 1, 2, and 4 (n5,278)
Financing Conditions differ p lt.001 Time p lt
.001 Interaction - NS
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Based on Our Social Cost Analysis, Reduced
Intensity of Services for Medicaid-Funded
Services May be Offset by Higher Expenditures by
Other Payers
25
Case-Mix Adjusted Annualized Costs for Adults
with Severe Mental Illnesses
Medicaid costs include health care and
transportation. Other public costs include off
budget health care cost, housing subsidies, legal
service, and volunteer cost. Private costs
include informal service provided by
families/friends, earned income, and out of
pocket fee if earned income equal to zero.
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Service and Organizational Recommendations
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Service Recommendations

• Set Access Targets for Carve-Out Services at
  Pre-Implementation Levels at a Minimum in All
  Areas
• Assure that the Service Network is Adequate to
  Provide Services to Persons with More Severe
  Illnesses

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Service Recommendations

• Assure Provision of Evidence Based Care for both
  Treatment and Rehabilitation
• Fidelity Measurement
• Benchmarked Outcome Data
• Explore Methods to Appropriately Expand Consumer
  Knowledge about and Direction of Care
• Particularly for Persons with More Chronic Care
  Needs

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Organizational Recommendations

• Implement Strategies to Independently Assure
  Adequacy of Data for System Monitoring
• Anticipate the Loss of Outcome Data for Networks
  Like those Used in Area 1 HMO
• Investigate Methods for Independently Collecting
  Encounter Data Including Sources of Care from
  Other Public and Private Payers

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Organizational Recommendations

• Assure Readiness to Provide Comprehensive Mental
  Health Benefits
• Demonstrated Capacity in MIS
• Demonstrated Management Capacity for
  Authorization and Payment
• Adequate Transition Strategies and Ramp-up Time

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Organizational Recommendations

• AHCA Should Develop, Test and Implement a Method
  to Assure Compliance with the 80 Rule
• Incomplete Encounter Data Frustrates Adequate
  Monitoring
• Consider Expanding Range of Carve-Out Services to
  Limit Cost Shifting within Medicaid Budgets
• Carefully Monitor Access to Specialized Services
  for Managed Care Enrollees
• Exclude Pharmacy Benefit and Explore other
  Methods to Control Pharmacy Costs
• Include Substance Abuse Services with Adequate
  Capitation Rate

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Organizational Recommendations

• Coordinate Efforts with DCF and Other Relevant
  Providers (Child Welfare, JJ, etc.) to
• Reduce Cost Shifting Among Public Payers
• Assure Most Effective and Efficient Delivery
  Strategies

33
Framing Evaluation Questions

• What are the implementation issues related to
  systems redesign and expansion
• What is the impact of managed care on Medicaid
  enrollees
• Access to care
• Health and mental health status
• Costs of care

34
Table 9. Annualized Formal Costs for Health
Services On and Off Budget (Adjusted)
Health services include general medical, vision
and dental care excluding transportation.
Significant at the 5 percent level.
Significant at the 1 percent level.
35
Managed Care Arrangements, Particularly in the
HMO Condition, have been Accompanied by
Consistent and Significant Problems with
Encounter Data - Frustrating Accountability
36
If Managed Care is to Accomplish its Goal of
Giving More to the State through Greater
Efficiency and Effectiveness of Management, We
Must Get More from Managed Care
37
Service and Organizational Recommendations
38
Service Recommendations

• Set Access Targets for Carve-Out Services at
  Pre-Implementation Levels at a Minimum in All
  Areas
• Assure that the Service Network is Adequate to
  Provide Services to Persons with More Severe
  Illnesses

39
Service Recommendations

• Assure Provision of Evidence Based Care for both
  Treatment and Rehabilitation
• Fidelity Measurement
• Benchmarked Outcome Data
• Explore Methods to Appropriately Expand Consumer
  Knowledge about and Direction of Care
• Particularly for Persons with More Chronic Care
  Needs

40
Organizational Recommendations

• Implement Strategies to Independently Assure
  Adequacy of Data for System Monitoring
• Anticipate the Loss of Outcome Data for Networks
  Like those Used in Area 1 HMO
• Investigate Methods for Independently Collecting
  Encounter Data Including Sources of Care from
  Other Public and Private Payers

41
Organizational Recommendations

• Assure Readiness to Provide Comprehensive Mental
  Health Benefits
• Demonstrated Capacity in MIS
• Demonstrated Management Capacity for
  Authorization and Payment
• Adequate Transition Strategies and Ramp-up Time

42
Organizational Recommendations

• AHCA Should Develop, Test and Implement a Method
  to Assure Compliance with the 80 Rule
• Incomplete Encounter Data Frustrates Adequate
  Monitoring
• Consider Expanding Range of Carve-Out Services to
  Limit Cost Shifting within Medicaid Budgets
• Carefully Monitor Access to Specialized Services
  for Managed Care Enrollees
• Exclude Pharmacy Benefit and Explore other
  Methods to Control Pharmacy Costs
• Include Substance Abuse Services with Adequate
  Capitation Rate

43
Organizational Recommendations

• Coordinate Efforts with DCF and Other Relevant
  Providers (Child Welfare, JJ, etc.) to
• Reduce Cost Shifting Among Public Payers
• Assure Most Effective and Efficient Delivery
  Strategies