Metrics, Money, and the Ethics of Behavioral Health Care. Joan L. Erney, JD Chief Executive Officer Community Behavioral Health December 2, 2013
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1 Metrics, Money, and the Ethics of Behavioral Health Care Joan L. Erney, JD Chief Executive Officer Community Behavioral Health December 2, 2013
2 Today s Conversation DBHIDS-Community Behavioral Health Current environment Trends in demand & need Funding trends & impact ACA impact Department of Behavioral Health & Intellectual disability Services
3 Overview of DBHIDS & CBH
4 PHILADELPHIA BEHAVIORAL HEALTHCHOICES PROGRAM Department of Behavioral Health Intellectual disability Services Community Behavioral Health Board of Directors Commissioner/DBHIDS President Director/Office of Services Vice President Deputy Commissioner- Finance and Secretary/Treasurer Commissioner/DHS Member Deputy Commissioner- Strategic Planning/DBHIDS- Member Deputy Mayor/Office of Health and Opportunity - Member Consumer / Family Representa@ve - Member HealthChoices Administra@ve Services Organiza@on (ASO) Medicaid Managed Care Office of Intellectual disability Services (IdS) Office of Addic@on Services (OAS) Office of Mental Health (OMH) Community Behavioral Health (CBH) Philadelphia Behavioral Health System
5 DBHIDS- Community Behavioral Health Created ASO (quasi governmental) - Community Behavioral Health unique model in the country Began in continue to meet the HealthChoices goals to increase access; enhance the quality of services, and stabilize Medicaid funding Approximately 460,000 Medicaid members Serve over 100,000 Members annually Contract with over 200 provider agencies for behavioral health services Continue to make significant investments to support evidence based practices, enhance quality and reward performance Department of Behavioral Health & Intellectual disability Services
6 Community Behavioral Health Administrative Services Organization Exist for the sole purpose of serving Philadelphia citizens Perform utilization review, program development, financial management, provider network and contracting for the BH system Since 1997, administrative costs remain the lowest in the State (in the country) at under 7%, resulting in high % of dollars for medical services and savings reinvested into community priorities Department of Behavioral Health & Intellectual disability Services
7 The Current Fiscal & Service Environment
8 Administrative Expenses Medicaid Managed Care Administrative Costs as a Percentage of Net Revenue National - 12% Pennsylvania - 8.5% (estimated) Philadelphia 5.77% (included in the 2013 capitation rate) Philadelphia Administrative Costs 46% of administrative costs are directly related to clinical care management expenses Costs have historically been held within the capitation rate allowance 14% 12% 10% 8% 6% 4% 2% 0% 12% National 8.70% 5.77% Pennsylvania Philadelphia
9 HealthChoices Enrollment and Utilization History Monthly Enrollment 490, , , , , ,000 Clients Receiving Services 120, ,000 80,000 60,000 40, , ,000 Enrollment Clients , Proj. Enrollment 366, , , , , , , , , , ,941 % change 1.1% 4.5% 6.5% 1.1% -0.2% 1.0% 3.2% 5.0% 4.9% -0.3% -1.1% Clients Receiving Services 71,552 75,859 82,709 86,336 87,155 92,114 99, , , , ,398 % of Enrollment 19.5% 19.8% 20.3% 20.9% 21.2% 22.2% 23.1% 23.2% 22.9% 23.5% 23.1%
10 Clients Total Medical Expenditures Clients Amount Paid Amount Paid $ $ $ $ $ $ $ $ $ $ Proj. Clients 71,552 75,859 82,709 86,336 87,155 92,114 99, , , , ,398 Amount Paid $426,235,911 $437,081,261 $543,216,632 $582,669,246 $596,816,580 $659,204,663 $686,966,065 $688,299,017 $688,981,269 $690,448,159 $698,114,504 $ Per Client $5,957 $5,762 $6,568 $6,749 $6,848 $7,156 $6,934 $6,589 $6,379 $6,252 $6,500
11 The Political & Economic Climate Photo source:
12 The Transforming Environment
13 The Transforming Environment Philadelphia systems transformation The Affordable Care Act Opportunities Challenges Preparation Data considerations
14 Philadelphia Systems Transformation Courts Child Welfare Schools
15 The Affordable Care Act Unprecedented opportunities & challenges for behavioral health
16 The Affordable Care Act: Opportunities Increased access to care Strengthened parity through the essential health benefits Movement toward more holistic, comprehensive services Funding opportunities for integrated care models Increased quality and accountability through outcomesbased financing Fostered innovation through financial incentives and program design flexibility
17 Essential Health Benefits What is essential? Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care Prescription drugs
18 The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) Goal is to increase individuals access to mental health and substance use services and treatment by limiting insurance companies ability to deny care IF an insurance company offers MH/SU services they must be offered at parity to physical health services Lifetime limits and other durations must be the same Preexisting condition limitations must be the same However, the essential health benefits provision mandates that mental health and substance use services must be covered in plans in the health insurance marketplace
19 The Affordable Care Act: Challenges Rapid promulgation of policies and constant change New rules and guidance are published every day Delays and changes to implementation are often occurring State policy decision-making Missed opportunities including Health Home participation and Medicaid Eligibility Expansion Decrease in entitlement programs and funding Workforce readiness Preparing for increase of individuals seeking services and treatment Maintaining compliance with state and federal regulations Lack of inclusion of behavioral health within Health Information Technology incentive programs
20 Medicaid Expansion & Healthy PA
21 Prevalence of Behavioral Conditions Among Medicaid Expansion Population: Pennsylvania, US 25% Uninsured Adults Ages with Incomes < 139% of the Federal Poverty Level (Pennsylvania: 482,704) 20% Prevalence Rate 15% 10% 5% I National Pennsylvania Confidence Interval 0% 7.0% 5.8% 14.9% 14.1% 14.2% 16.4% Serious Mental Illness PA CI: 3.6% - 9.1% U.S. CI: 6.3% - 7.7% Serious Psychological Distress PA CI: 9.9% % U.S. CI: 14% % Sources: National Survey on Drug Use and Health (Revised March 2012) 2010 American Community Survey Substance Use Disorder PA CI: 11.4% % U.S. CI: 13.2% % CI = Confidence Interval Presentation by Kevin Malone, SAMHSA, HHS, May 2013
22 Preparing for Health Reform
23 DBHIDS & CBH Health Reform Priority Areas Eligibility & Enrollment/ Medicaid Expansion Integrated Care Models Health Information Technology/Reporting Workforce Development Essential Health Benefits/ Parity
24 Public Health Policy & Planning Unit Leads health reform preparation and implementation efforts Leads a health reform steering committee comprised of membership from across DBHIDS & CBH Publishes regular newsletters, policy updates and web materials to increase knowledge and awareness of ACA and state policy issues Provides extensive training and technical assistance to DBHIDS & CBH staff, providers, and community partners Works collaboratively across the Department to respond to policy issues and plan strategically
25 Data Considerations Measures should: Reflect values of a recovery oriented system of care Include behavioral health in addition to physical health outcomes for integrated care models Accurately reflect the patient s experience
26 DBHIDS Resources DBHIDS Public Health Policy & Planning Resources on dbhids.org Social media Publications Monthly Newsletter Bimonthly Policy Update Upcoming events & trainings Regulations database Information requests to
27 Health Reform Resources Healthcare.gov Localhelp.healthcare.gov healthreformgps.org
28 Questions?
29 Thank you!
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