Post on 31-Mar-2015
Evaluation Results of the Prepaid Mental Health Demonstration:
Year 7 - Areas 1 and 6
Briefing for the Substance Abuse and Mental Health Corporation
August 4, 2004
David L. Shern, Ph.D.
and the Evaluation Team
Louis de la Parte Florida Mental Health Institute
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?
Financing Condition
Health Mental Health
Pharmacy
Areas 1 & 6
MediPass/PMHP No Risk At Risk No Risk
Areas 1 & 6
HMOs At Risk At Risk At Risk
Areas 2, 4, & 7
MediPass No Risk No Risk No Risk
Financial Risk Arrangements
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
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
Area 6 Funding Streams as of 4/04
Agency for Health Care Administration
UBH
FHP/VO
MG
MHC
Northside
PR
WH
AmGHESTAY UHC
Community Mental Health Centers AssociateProv.
Solid line – CapitationDotted line – Fee for service
Other Providers
SA, SIPP, FACT, BHOS, STFC, & Comprehens. Assessment
Providers
Medicaid enrollees not eligible for managed care
WBH
Provider Networks
Area 1
– The PMHP and HMO have different provider networks
– Fee-For-Service for HMO Relationships
– Capitation for PMHP
Agency for Health Care Administration
ABHLVC
BW
COPE
HE
Providers(excluding LV)
Solid line – CapitationDotted line – Fee-for-service
Associate Providers
Area 1 Funding Streams as of 6/04
SA, SIPP, FACT, BHOS, STFC, & Comprehens. Assessment
Providers
Medicaid enrollees not eligible for managed care
WCBH
What Have We Learned?
The HMO Business Arrangements Have been Accompanied by Greater
Instability and Complexity in Organizational Arrangements
Agency for Health Care Administration
APS Horizon UBH CBC
FHP
MG
MHC
Northside
PR
WH
ValueOptions
St.A. FL 1st PHP HESTAY PCAUHC
Community Mental Health CentersOther Providers
AssociateProv.
ALP
MAG
MHC(CMHC)
MHC(CMHC)
WEL
BHM
Organizational Structure: Funding Streams as of 1/00
Area 6 Funding Streams as of 3/02
Agency for Health Care Administration
UBHCBC
FHP/VO
MG
MHC
Northside
PR
WH
ST.AFL 1st PHP HESTAY UHC
Community Mental Health Centers AssociateProv.
CMHC
HZ
Black = FFS Blue = Outpatient capped only Red = Outpatient & Inpatient capped Dotted line = Risk Sharing
Other Providers
Figure 6. Area 6 Funding Streams as of 4/04
Agency for Health Care Administration
UBH
FHP/VO
MG
MHC
Northside
PR
WH
AmGHESTAY UHC
Community Mental Health Centers AssociateProv.
Solid line – CapitationDotted line – Fee for service
Other Providers
SA, SIPP, FACT, BHOS, STFC, & Comprehens. Assessment
Providers
Medicaid enrollees not eligible for managed care
WBH
Implementation of Managed Care
Has Not Resulted in Improved Access to Services
Average 6-Month Penetration for Carve-Out Services: Areas 1, 2, and 4
0 . 0 %
2 . 5 %
5 . 0 %
7 . 5 %
1 0 . 0 %
1 2 . 5 %
1 5 . 0 %
1 7 . 5 %
J u l - D e c2 0 0 1
J a n - J u n2 0 0 2
J u l - D e c2 0 0 2
J a n - J u n2 0 0 3
F is c a l Y e a r
Pen
etra
tion
Rat
e
P M H P A r e a 1
H M O A r e a 1
M P A r e a 2
M P A r e a 4
Case Mix Adjusted
Average Annual Penetration for Carve-Out Services Only: Areas 6, 4 and 7
0%
5%
10%
15%
20%
25%
95-96 96-97 97-98 98-99 99-00 00-01 01-02 02-03
Fiscal Year
Per
cent
age
Who
Use
d S
ervi
ces
PMHP Area 6
HMO Area 6
MP Area 7
MP Area 4
Case Mix Adjusted
People with Schizophrenia enrolled in HMOs, which are at risk for pharmaceutical expenses, are
less likely to receive atypical antipsychotic medications
Atypical Penetration Areas 4 & 6
Adult Schizophrenia Diagnosis Only
0 %
1 0 %
2 0 %
3 0 %
4 0 %
5 0 %
6 0 %
7 0 %
8 0 %
9 0 %
9 5 9 6 9 6 9 7 9 7 9 8 9 8 9 9 9 9 0 0 ' 0 0 0 1 ' 0 1 0 2 ' 0 2 0 3
H M OP M H PM P 4
Enrollees are Receiving Fewer Services or Less Intensive Services in the Managed Care Conditions
HMO Enrollees Receive Fewer Services than Persons in the PMHP
PMPM Standard Costs by Category: Areas 1, 2 & 4 (Case Mix Adjusted)
Expenditure Category HMO 1 PMHP 1 MP 4 MP 2
Carve Out Mental Health $16.64 $23.86 $29.36 $30.71
Mental Health Services in the Health Sector
.86 4.71 4.02 3.22
Substance Abuse Services Paid by MCO
1.08 .00
Total Non-Pharmacy MH/SA Expenditures in Plan
$18.57 $23.87 (rows 1+3)
$33.38 $33.93
Pharmacy 13.47 21.01 23.94 20.09
Fee for Service MH Services Outside of Carve Out
2.69 5.46 5.72 5.31
Fee for Service SA .14 1.51 1.67 1.16
Total Mental Health $34.87 $56.56 $64.70 $60.49
PMPM Standard Costs by Category: Areas 6, 4 and 7 (Case Mix Adjusted)
Expenditure Category HMO 6 PMHP 6 MP 4 MP 7
Carve Out Mental Health $6.94 $11.85 $28.72 $31.46
Mental Health Services in the Health Sector
1.12 5.60 5.89 9.05
Substance Abuse Services Paid by MCO
0.94 0.01
Total Non-Pharmacy MH/SA Expenditures in Plan
$9.00 $11.86(rows 1+3)
$34.61 $40.51
Pharmacy 7.71 22.83 25.53 28.83
Fee for Service MH Services Outside of Carve Out
3.29 4.71 7.22 6.64
Fee for Service SA .15 1.70 1.75 1.43
Total Mental Health $20.15 $46.70 $69.11 $77.41
Reduced Intensity of Services has Generally Not
Been Associated with Poorer Outcomes for
Managed Care Enrollees
Youth in Area 1 Require Further Study to Explain
Poor Outcomes
Change in Predicted GAF Score Over Time For Ages 21-64 in Areas 1, 2, and 4 (n=5,278)
Financing Conditions differ p <.001Time p < .001; Interaction - NS
45
47
49
51
53
55
0 3 6
Time in Months
Pre
dict
ed G
AF
Sco
re
PMHP Area 1
HMO Area 1
MP Area 2
MP Area 4
Based on Our Social Cost Analysis, Reduced Intensity
of Services for Medicaid-Funded Services May be
Offset by Higher Expenditures by Other
Payers
Case-Mix Adjusted Annualized Costs for Adults with Severe Mental Illnesses
HMO(n=250)
PMHP(n=208)
FFS(n=171)
Total(N=629)
p for Two Way Comparison*
HMO vs.
PMHP
PMHP vs.
FFS
HMO vs.
FFS
Medicaid costs*
$ 5,681 $ 9,844 $ 8,414 $ 7,725 .01 .30 .02
Other public costs**
$ 8,162 $ 7,457 $ 6,464 $ 7,588 .12 .04 .00
Private costs***
$ 5,587 $ 5,744 $ 1,060 $ 4,258 .86 .00 .00
Societal costs $19,199 $22,062 $15,967 $19,399 .15 .00 .00* 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.
Service and Organizational
Recommendations
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
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
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
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
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
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
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
Table 9. Annualized Formal Costs for Health Services On and Off Budget (Adjusted)
HMO
(n=250)
PMHP
(n=208)
FFS
(n=171)
Total
(N=629)
PH - On
Off
$2,229
$ 33
$5,018
$ 57
$2,021
$ 14
$2,886*
$ 37*
MH - On
Off
$2,387
$ 166
$2,117
$ 255
$3,563
$ 367
$2,815
$ 294
Rx - On $1,003 $2,536 $2,469 $1,885**
Off $ 314 $ 88 $ 107 $ 195**
Total - On
Off
$5,640
$ 513
$9,747
$ 398
$8,319
$ 487
$7,641*
$ 526
Grand Total $6,153 $10,146 $8,806 $8,167*
Health services include general medical, vision and dental care excluding transportation. * Significant at the 5 percent level. ** Significant at the 1 percent level.
Managed Care Arrangements, Particularly in the HMO Condition, have been
Accompanied by Consistent and Significant Problems with Encounter Data - Frustrating
Accountability
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
Service and Organizational
Recommendations
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
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
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
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
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
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