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Mark F. Botts, J.D.Associate Professor of Public Law and GovernmentSchool of GovernmentThe University of North Carolina at Chapel Hill

David R. Swann, MA, LCAS, CCS, LPC, NCCChief Clinical OfficerPartners Behavioral Health Management2013

Area

Authority

Local

Management

Entity (LME)

Managed

Care

Organization

(MCO)

� The board is responsible for all powers and duties conferred on the area authority

� The authority to carry out those responsibilities resides with the board until some is given away (delegated) to others

� Board role is not to carry out all responsibilities

� Board role is to be accountable for all responsibilities (to ensure the LME “works”)

Total Authority-Total Accountability(within the law or other external authorities)

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Examples Examples

Adopt a budget Adopt meeting agendas

Evaluate CEO Establish committees

Monitor finances Set communication protocols

Monitor services Set member responsibilities

Governing the Governing the Agency

Managing Board Managing Board Work

� General Statutes

� Session Laws

� North Carolina Administrative Code

� DMH contract

� DMA contract

� Federal law

These govern not only how we pay for and deliver services but also the collection, analysis, and reporting of data about service payment, delivery, and outcomes.

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If an LME operating under the Waiver fails to meet performance expectations of an approved contract, DHHS must reassign the LME’s Waiver (managed care) functions to another LME

S.L. 2012-151 (S 191)

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� MH/DD/SAS Community Systems Progress Report and Critical Measures at a Glance (quarterly) www.ncdhhs.gov/mhddsas/statspublications/Reports/DivisionInitiativeReports/communitysystems/index.htm

� North Carolina LME/MCO Performance Measurement and Reporting Guide, Sept 17, 2013 (DMA and DMH/DD/SAS)

� LME-MCO Monthly Monitoring Report, September, 2013

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� DHHS must certify every 6 months that LME has made◦ Adequate provision against risk of insolvency

◦ Timely provider payments

◦ Adequate exchange of information (billing, payment, other transaction data) with DHHS and providers

� If certification is not made, DHHS must reassign contract responsibilities to another LME/MCO and dissolve the noncompliant LME/MCO

S.L. 2013-85 (S 208)8

� Adequate provision against risk of insolvency� Timely submission of financial reports

� No consecutive 3-month periods when ratio of current assets to current liabilities is less than 1 (based on review of balance sheets for each mo.)

� LME meets DHHS monitoring team’s “solvency measures”

� Timely provider payments� No consecutive 3-month periods during which the LME has paid less than 90% of clean claims w/n 30 days of receipt of claim

S.L. 2013-85 (S 208)9

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If at any time an LME/MCO is not in compliance with other requirements of the Contract, DHHS must◦ Notify LME in writing

◦ Allow LME 30 days to demonstrate compliance

◦ Reconsider determination

◦ If LME still noncompliant, allow 30 days for LME to negotiate a merger with another LME

◦ If negotiations not successful, assign contract of noncompliant LME’s contract to a compliant LME

◦ Oversee transfer of operations and contracts

◦ S.L. 2013-85 (S 208) 10

Information Management

AccessProvider Relations� capacity� enrollment� monitoring

Service Management � authorization� utilization� care coordination

Quality Management Community Collaboration

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G.S. 122C-121 and -111

Director•Planning•Implementing•Monitoring

� Appoint an area director� Evaluate annually the area director for performance based on criteria established by the board and DHHS◦ Monitoring involves both� Setting expectations or criteria, and� Making an assessment or judgment based on those expectations

� The board is accountable for the CEO doing his/her job and doing it well � The CEO’s job:◦ Appoint, supervise, and discipline staff◦ Administer MCO/LME functions◦ Administer budget and fiscal controls

-GS 122C-121

� The CEO is not accountable for what the board's job is or that the board does its job well

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� 10A NCAC 27G .0507—DHHS evaluation criteria: ◦ maintaining effective relationships with the area board, the CFAC, and the community served

◦ recruiting, monitoring, and maintaining effective relationships with qualified providers

◦ encouraging consumer and family involvement in system management activities

◦ managing human and fiscal resources◦ demonstrating leadership skills

� Board may use the director evaluation as an opportunity to create an annual plan for the CEO that includes policy and programmatic considerations

� Adopt an annual balanced budget

� Select and hire a CPA to◦ Audit the LME’s accounting records

◦ Report directly to the board

� Establish a finance committee that◦ Meets at least 6 times a year

◦ Reviews the financial strength of the LME

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� Monthly financial reports to the LME Board

� Quarterly financial reports to the counties served by the LME

� Annual financial statements that set out

◦ Financial results of operations during the year

◦ Financial position as of the end of the fiscal year

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� Maintain a restricted risk reserve account

◦ equal to 15% of the annualized cost of state contract

◦ to fund payments to meet outstanding obligations such as cost overruns related to program services covered by the contract

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� Claims Processing◦ Review provider claims for proper documentation

◦ Pay claims promptly according to State requirements

� 1st and 3rd Party Collections◦ Implement the family income co-payment schedule adopted by the DHHS

◦ Make every reasonable effort to collect appropriate reimbursement for the costs of services from individuals or entities able to pay (G.S. 122C-146)

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� Maintain an IT infrastructure compliant w/ federal law (privacy, security, electronic health records)

� Maintain accurate and up-to-date consumer information and eligibility records

� Submit to DHHS, and ensure providers submit to the LME, timely consumer info (screening, admission, discharge, eligibility determinations)

� Maintain a website that includes current and accurate info on how consumers and families may access services

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ddddd

AccessProvider Relations� capacity� enrollment� monitoring

Service Management � authorization� utilization� care coordination

Quality Management Community Collaboration

Implement a system that responds to citizen requests for services:

screening, triage, and referral (STR) system available 24/7 that connects citizens to community services

crisis-response system that responds with appropriate emergency services

Access patterns and trends reported to the Board, CFAC, and State�number of persons requesting services�number determined to need emergent,

urgent, and routine care�number for which access is provided

within times defined in state performance standard

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� Ensure the availability of qualified providers to deliver services

�Develop the capacity of providers and control the quality of their services (enroll, credential, and monitor)

� Submit quarterly service delivery reports to counties and state

Types of services delivered Number of persons served Services requested but not delivered

� Submit to DMA ◦ Findings of LME’s own provider network

analyses ◦ If network gaps are identified, a network

development plan

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� Approve specific services to individual consumers—“service authorization”

� Evaluate the medical necessity, clinical appropriateness, and effectiveness of services according to state criteria—”utilization management”

� Monitor individual care decisions at critical treatment junctures to assure effective care is received when needed—“care coordination”

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� To LME Board--quarterly reports on service utilization patterns� To State—data on◦ Utilization of services by service type (e.g., inpatient,

intensive outpatient, emergency department)◦ Treated prevalence—number who received

treatment for a particular condition (by age-disability group) compared to number estimated to have that condition

◦ Percent of authorization requests processed in the required time frame

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� Implement procedures for monitoring and evaluating the quality of services

� Establish a quality assurance/performance improvement committee ◦ to identify and address opportunities to improve LME operations and the local service system

◦ engage in performance improvement projects

◦ report regularly to the governing board

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Analyze access, service authorization, and claims payment data for: ◦ high cost/high need consumers

◦ provider billing patterns and trends

◦ utilization of various services in the service array

◦ gaps in the service array

◦ consumer movement among providers

◦ consumer access, initiation, engagement and retention

◦ continuity of care and personal consumer outcomes

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The QM Committee must review and quarterly report to Board and CFAC: �consumer trends (client outcomes, use of emergency services and state hospitals, perceptions of care)

�provider trends and performance (service capacity, provider quality)

�LME operations (trends in volume and cost of services per consumer, access system, management of state funds)

� Timely access to care

� Services to persons in need (penetration rate)

� Timely initiation and engagement of service

� Effective use of state hospitals

� State psychiatric hospital readmissions

� Timely follow-up after inpatient care

� Child services in non-family settings

� Personnel

� Budget and Finance

� Consumer Affairs

� Business management

� Services ◦ Access

◦ Provider relations

◦ Service management

◦ Quality management

◦ Community collaboration

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To efficiently provide necessary

and effective services to eligible

people within available resources

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� Organizational purpose (ENDS)

� Organizational activity (MEANS)

-----------------------

� Are we accomplishing our purpose?

� Have our expectations been met?

-----------------------

� To demand a relevant and credible accounting of performance, you must first state your expectations (with one voice)

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Monitoring with Reports

Data:• What are we measuring?• Why are we measuring it?

Performance Goals:• What do we plan to do?• Why do we plan to do it?

Outcomes:Have we met our performance goals?

� End. Effective services . . . (“timely access to care”)

� Means. 24/7/365 telephonic STR process for citizens to access services and for the LME to respond emergencies

� Performance goals. Calls answered w/n 30 secs. (95%). Abandoned calls (<5%). Timeliness of face-to-face contact for routine (14 days), urgent (48 hrs.), and emergent needs.

� Data. Access patterns/trends report to Board, data reported to DMH and DMA and compiled by State

� Outcome. Did LME meet state performance goals?

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� End. To efficiently provide necessary and effective care to eligible people w/n available resources

� Means. Annually determine client needs and assess ability to meet that need (service needs and provider capacity)

� Performance goal. Submission of gap analysis and service/needs assessment to DHHS that meets the requirements developed by DMA and DMH

� Data. Document meeting DMA and DMH requirements was submitted or not submitted

� Outcome. Was “performance” goal met?

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� End. Efficiently provide effective and necessary services to eligible people w/n available resources Means. Individual care decisions at critical treatment junctures to assure that client care is coordinated, received when needed, likely to produce good outcomes

� Data. (1) % of persons receiving follow-up care within specified time after discharge from inpatient facility, (2) % of inpatient facility admissions that were readmissions within 30 days, (3) % of readmissions assigned a care coordinator.

� Performance goal. (1)____, (2) _____, (3) 85%

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1. Establish a Consumer and Family

Advisory Committee (CFAC)

2. Establish a client rights committee� monitors services for compliance w/ client rights

� establishes review procedures for client

complaints

3. Perform public-relations and

community-advocacy functions

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� End. Consumer satisfaction with quality and quantity of services

� Means. Review procedures that timely respond to and resolve consumer questions and complaints

� Performance goal. 90% of complaints resolved in 30 days

� Data. Submitted to DMA and DMH.

� Outcome. LME performance compared to state performance goal

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Mark F. Botts, J.D.Associate Professor of Public Law and GovernmentSchool of GovernmentThe University of North Carolina at Chapel Hill

David R. Swann, MA, LCAS, CCS, LPC, NCCChief Clinical OfficerPartners Behavioral Health Management2013

� Not my mother’s mental health center any longer.

� Few common locations for centralized services in counties.

� Many new providers emerged.

� Behavioral Healthcare moves into mainstream healthcare (Supply-Demand-Commerce-Profit Drivers).

� LME/MCOs are not mental health centers any longer.

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� For Board Members

� For Consumers

� For Providers

� For Managed Care Organizations

� For Taxpayers (County, State and

Federal)

� Accrediting Organizations

� The solution is a system redesign and better

management of the care.

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� There is nothing that goes on in the organization that the board has not either caused or allowed.

� What decisions and judgments do board members need to make, and what information do we need to have?”

� The challenge is for the board to understand and carry out its distinctive role as a body

� Polices to the rescue.

� If you have not said how it ought to be, then don’t ask how it is.

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�Monitoring through data and reports

�Delegation of operations

� Identifying and listening to owners

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�� Improved Improved AccessAccess

��Better CareBetter Care

��Potential Cost ReductionPotential Cost Reduction

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� Medicaid is the largest payer for behavioral health services (includes substance abuse/dependence).

� 11% of Medicaid eligibles receive behavioral healthcare.

� Behavioral healthcare accounts for 30% of Medicaid expenditures.

� Escalating costs – two North Carolina reports since January 2013� Shrinking Revenue� Calls for accountability� Pressures from stakeholders (patients,

providers, payers, etc.) � Health Homes and Accountable Care

Organizations are tools in Health Care Reform to manage care and improve outcomes.

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� There are only three states without some Medicaid managed care --New Hampshire, Alaska and Wyoming.

� Behavioral Health Carve Out Model with Health Homes are being tested in several states (MO, RI, AZ, IA, OH, KS).

� Many states are moving ‘disabled’ populations (including populations with SMI) from fee-for-service financing model to a managed care financing model.

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� Certain types of Medicaid Managed Care waivers are designed to manage the growthof Medicaid funding while, at the same time, maintaining high quality behavioral healthcare benefit plans.

� The objective is not to limit services for individuals, but to manage a system so that a person is guided to the appropriate level of care.

� A Medicaid Waiver is a mechanism giving the authority and resources to Manage a System of Care (all resources).

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� Initial and Continued Stay Authorizations

� Provider Network Development, Enrollment, Credentialing and Monitoring

� Care Coordination for certain recipients

� Quality Improvement Activities

� Payment of Medicaid Claims

� Partnership with CCNC Networks to care coordinate and improve outcomes

� Fraud, Waste and Abuse

� Managing for Outcomes

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� Controlling the selection of the professionals and provider organizations in a particular delivery system

� Setting service payment rates and methodologies

� Setting clinical best practice policies

� Establishing the framework for the measurement of clinical quality and performance

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� Pennsylvania example: Behavioral Health Choices generated $4 billion in savings from 1997-2007.

� Massachusetts example: A 50% reduction in ED visits and a 71% reduction in psychiatric admissions for Medicaid enrollees over the 3-year period 2007-2010.

� Colorado example: MBHOs operating in CO for 14 years have contained increases in their capitation rate to 13.8%, far less than the inflation rate of 44% and the inflation rate of medical care of 82%.

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� Mental health payers are expanding◦ Federal parity expands to Medicaid and the Health Insurance Exchanges effective 1/1/2014

◦ National growth of Managed Care – particular expansion in Medicaid. 40 States increased their prevalence of Medicaid Managed Care in 2012 or planned to in 2013.

◦ Behavioral health is the “critical path” to saving health care dollars

◦ Integration of physical and behavioral health treatment is viewed as the critical path to improving health outcomes.

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� Accountability for a population (public health model). E.g. the greatest risk for a Managed Care Organization are the enrollees that are not engaged in treatment.

� Renewed focus on Better Care

� Providers are going to have to deliver outcome-based care and manage inside alternative payment models that are not fee-for-service but value-based strategies (pay for impact).

55David R. Swann, CCO, Partners Behavioral

Health Management

1. Identify at least three owners of the LME/MCO

2. Why are they an owner?

3. How do you as a board member represent them?

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� Board members hold some of value in trust for someone else – Trustee

� The board is legally accountable to owners –Example: through a North Carolina state plan amendment, the Federal government authorizes Partners to operate a Medicaid health plan pursuant to a formal contract and both Federal and State funds are expended to operate the health plan. Partners exists to be accountable to the health plan contract.

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� Policy governance acknowledges the obligation to the legal owners, but also acknowledges “moral ownership” – pointing to a broader responsibility to the various stakeholders. (this can be many)

� Linking with the ownership is one of the board’s main job products and main activities.

� Great boards links with owners by creating ways to include owner values in the policy and governance work of the board.

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� Great boards expend a considerable amount of time and

energy invested in ownership linkage activities. Examples:

1. Checking the weather (big-picture, external,

uncontrollable trends and issues that might affect Partner’s ability to set or accomplish its ENDS.

2. Adjusting ENDS policies in response to the findings in #1

3. Proactive inspiration of and consultation with the moral

owners.

4. Clearly understanding the obligations to the legal owners

and adjusting ENDS policies to meet the obligations.

5. Respond to the question: What can Partners do to benefit

the legal and moral owners?

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� Board members have between 20-40 hours per YEAR to govern.

� Successful governance requires:◦ Ends and Means policies

◦ Executive policies defining the boundaries of functioning

◦ Ends policies that define the ENDS should have data reports regularly provided for great governance

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� Dashboards may have various components.

� Suggested metrics related to successful managed care include:

� Medical Loss Ratio

� Prevalence and Penetration Rates

� Utilization Data by Service Category showing trends in the reduction of inappropriate levels of care and appropriate care matched to levels of need.

� Relevant outcome measures such as readmission rates, engagement in care, transitional care connections.

� Service Authorization Denials

� Claims processing (payment to providers)

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� Framework of plan to reform Medicaid in North Carolina –

Initiative by Governor and Secretary of North Carolina

Department of Health and Human Services.

� Essential Elements:

1. Capitated – full risk managed care

2. Comprehensive Care to include physical health care

3. Controls growth of Medicaid by reducing overall healthcare costs

4. Outcome driven – better care goal

5. Desire to contract with private vendors of managed care� Profit-driven Medicaid managed care companies have become some of the

nation’s fastest growing and most sophisticated business enterprises. Directly or indirectly through subcontractors they employ hundreds of thousands of people, report billions of dollars in annual revenues and now,

according to federal statistics, have about half the country’s 62 million Medicaid patients enrolled in their plans.

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� Kansas – similar to NC - KanCare◦ Launched privatized Managed Care January 2013

◦ Begins comprehensive care with integration of physical health July 1, 2014. Persons with Severe and Persistent Mental Illness, Severe Mental Illness and Severe Emotional Disturbance require to have a Health Home.

◦ Three Managed Care Organizations

◦ Governor seeks to save $900 Million over five years

◦ Competitive RFP

◦ Open enrollment statewide for any of the three MCOs.

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� Provider enrollment and contracting was slow.

� Managing service utilization is conserving Medicaid in year

one.

� MCO vendors are resisting transparency and claiming trade secrets as defense.

� Value-based contracting is on the horizon and providers

don’t know how to respond.

� Challenge will be after cost savings in year 1 and 2 through utilization management, continued the cost savings through

better care and improved access.

� No improved care outcomes in year 1

� Slow payments to providers

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•MBHO’s contracted to provide

intensive treatment and wrap-

around services in the community

for children which reduced hospital

admissions.

•MBHO’s contracted to provide

intensive treatment and wrap-

around services in the community

for children which reduced hospital

admissions.

Michigan

example:

•Medicaid clients receiving care

coordination had 92% lower

inpatient service costs.

•Medicaid clients receiving care

coordination had 92% lower

inpatient service costs.

New York

example:

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• Behavioral Health Choices generated $4

billion in savings from 1997-2007.

• Behavioral Health Choices generated $4

billion in savings from 1997-2007.

Pennsylvania

example:

•A 50% reduction in ED visits and a 71%

reduction in psychiatric admissions for

Medicaid enrollees over the 3-year period

2007-2010.

•A 50% reduction in ED visits and a 71%

reduction in psychiatric admissions for

Medicaid enrollees over the 3-year period

2007-2010.

Massachusetts

example:

•MBHOs operating in CO for 14 years

have contained increases in their

capitation rate to 13.8%, far less than

the inflation rate of 44% and the

inflation rate of medical care of 82%.

•MBHOs operating in CO for 14 years

have contained increases in their

capitation rate to 13.8%, far less than

the inflation rate of 44% and the

inflation rate of medical care of 82%.

Colorado

example:

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