Erie County Department of Mental Health Adult Leadership Meeting

Challenges & Opportunities in Emerging Managed Care/RHBO

Environment

WESTERN REGION BEHAVIORAL HEALTH ORGANIZATONWITH BEACON HEALTH STRATEGIES, LLC AND COORDINATED CARE SERVICES, INC

November 7, 2012

AGENDA

Review behavioral health managed care programs already in place focused on how they assess performance/impact Pennsylvania HealthChoices Beacon Select

What might we learn from these programs that could help us prepare for the future?

Next steps

HealthChoices: Pennsylvania Behavioral Health Managed

Care Program

HealthChoices: Pennsylvania Behavioral Health Managed Care Program

Requires that BH Managed Care Organizations (BH-MCOs) supporting the publicly funded system participate in the State’s Performance /Outcomes Management System (POMS)

Database managed by PA’s Department of Public Welfare (DPW).

Produces set of performance measures/ indicators DPW uses as tool for continuously evaluating (CQI) the effectiveness of the BH-MCO contractors in achieving system level outcomes.

PA HealthChoices:Outcome Dimensions Increase Community Tenure and Less

Restrictive Services Increase Vocational and Educational Status Reduce Criminal/Delinquent Activity Improve Health Care Increase Penetration Rates Increase Consumer/Family Satisfaction Implement continuous quality improvement (CQI)

Actions Increase Range of Services and Improve

Utilization Patterns

PA HealthChoicesOutcome Dimensions Detail Increase Community Tenure and Less Restrictive

Services Increase in appropriate use of BH inpatient days Decrease criminal incarcerations Increase appropriate use of MH residential care Decrease out-of-home placements Decrease homelessness Decrease placements in C& Y custody Increase residential stability

Increase Vocational and Educational Status Increase school attendance Increase school performance Improve school behavior Increase vocational status for adults

PA HealthChoices Outcome Dimensions Detail Reduce Criminal/Delinquent Activity

Reduce number of arrests Reduce positive drug screens Improve probation/parole status Reduce status offenses (focus on truancy)

Improve Health Care Meet of exceed DPW’s EPSDT screening Increase % of consumers with annual physical

exams Reduce hospital medical ER use

PA HealthChoicesOutcome Dimensions Detail Increase penetration rates (% of enrollees who

received BH treatment thru BH contractor) Increase appropriate utilization by priority group and type of

service Increase appropriate utilization by age and type of service

Increase Range of Services and Improve Utilization patterns Improve/increase array of trxt, support and rehab service

options Decrease % of priority group consumers using only inpatient

and/or ER services Reduce inpatient re-hospitalization rate Reduce rate of perinatal addictive disorders Reduce “drop-out” rates

Beacon Select Initiative

What is it?Managed Care Program Model Pilot: Now in MA and moving into NY

Purpose: Create a more sustainable model of BH care that supports a system of care for the client (effective linkages among services) and create a set of metrics that will support and monitor such development.

Redistribute administrative resources to target effective aftercare and support transition to the community.

Target resources to assist outlier providers in appropriately managing utilization and quality measures, thus focusing attention on the providers for whom there will be the greatest impact.

Transition the managed care process from an adversarial relationship of routine member management to a more collaborative and sustainable model. This enhanced collaboration will shift focus to ensuring access of quality care for members while containing cost through aggregate data management.

Beacon Select Initiative Program Goals

Beacon Select InitiativeFACTORS CONTRIBUTING TO SUCCESS

Senior Management

o A commitment from all levels of the organization is necessary, including the CEO and Medical Director.

Medical Necessity Criteria

o In addition to having the utilization review staff understand Beacon’s Medical Necessity Criteria, it is imperative that the UR staff have the conversations around medical necessity during internal meetings that the managed care entity would have in a more traditional utilization management approach.

Infrastructure

o Providers that have been successful with the Beacon Select Initiative have an infrastructure in place that allows self management to occur.

Communication

o Select providers are assigned a Beacon Select Clinician. The provider is asked to designate staff to review systems issues, barriers to treatment or community resources.

Beacon Select Initiative

Inpatient Processes

and

Procedures

Beacon Select InpatientADMISSIONS

There are no changes to the admission process for Beacon Select providers. Initial authorization is obtained in the same way regardless of whether the admission is to a Select or Non-Select provider.

Following admission; Select providers are not required to complete utilization reviews to obtain authorization for continued stay.

Authorizations are maintained by Select providers through an electronic portal.

Authorizations for inpatient admission at Select facilities will trigger treatment plan and discharge plan templates that can be accessed through Beacon’s web portal.

Beacon Select InpatientPROVIDER SUCCESS IS DETERMINED THROUGH MEASUREMENT OF THE SELECT INITIATIVE’S KEY METRICS

Average length of stayRate of coordination between

provider and PCP

7 / 30 day readmission ratesRate or coordination between provider and outpatient BH

providers

Administratively necessary days Aftercare appointment rate

scheduled by facility within seven days of discharge

Beacon Select InpatientANALYSIS AND REVIEW

During the initial six months of a provider’s participation in the Beacon Select Initiative, provider performance on the identified metrics will be reviewed.

After the initial six month period, provider performance will be measured and an assessment of provider performance will be completed. The provider will be supplied with data before and after participation in the Select Initiative.

All providers in the Select program have a site visit by the Beacon Select management team to review facility specific data. This site visit includes action items to identify best practices and opportunities for improvement.

For providers that do not maintain performance within the identified targets, additional analysis will be completed to determine if other factors should be considered. Beacon Select status may be lost, in which case the provider returns to Beacon’s standard UM procedures.

Beacon Select Outpatient

Outpatient Processes

and

Procedures

Beacon Select Outpatient targets high volume outpatient mental health providers who, in addition to meeting utilization targets, have demonstrated quality in the delivery of care.

Participating providers only register members annually with Beacon to receive outpatient services authorization-free. (Psychological testing is excluded).

“Report Cards” are distributed monthly measuring utilization and quality metrics.

Beacon Select Outpatient

Selection

PARTICIPATING PROVIDERS FALL INTO THREE CATAGORIES:

1.Very low utilization. Goal: Monitor to ensure there is no significant increase in utilization.

2.Average utilization. Goal: Maintain current utilization.

3.Utilization slightly above average. Goal: Modest reduction in utilization.

Beacon Select Outpatient

Beacon Select Outpatient

PROVIDER SUCCESS IS DETERMINED THROUGH MEASUREMENT OF THE SELECT INITIATIVE’S KEY METRICS

Average number of visits per utilizer by the Select Provider vs.

the network average

Percentage of utilizers who have a crisis evaluation following at least two outpatient visits at the Select Provider vs. the network average.

Percentage of utilizers at Select Provider who are managed within 12 visits vs. network average.

Percentage of utilizers for whom the Select Provider has made PCP contact within the past 12 months .

Percentage of utilizers who have an inpatient admission following at least two outpatient visits at the Select Provider vs. the network average.

Percentage of utilizers for whom an outcomes tool was used as a baseline.

Other Possible Sources of Information

WRBHO Quarterly Reports Ideas generated through the small group

conversations that took place during the June BEST Meeting

OMH BHO Portal- metrics for state and region

WRBHO Inpatient Psychiatric Experience Report (due out mid November)

Health Home work now taking place

What do we see in the approaches these models take that we might want to pay attention to?

Systems metrics Other

Next Steps…

How do we best use data to support change in the county as we move towards some form of BH managed care?

How can the BHO be of assistance?