Metrics, Money, and the Ethics of Behavioral Health Care Joan L. Erney, JD Chief Executive Officer Community Behavioral Health December 2, 2013
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
Overview of DBHIDS & CBH
PHILADELPHIA BEHAVIORAL HEALTHCHOICES PROGRAM Department of Behavioral Health Intellectual disability Services Community Behavioral Health Board of Directors Commissioner/DBHIDS President Director/Office of Addic@on Services Vice President Deputy Commissioner- Finance and Administra@on/DBHIDS 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
DBHIDS- Community Behavioral Health Created ASO (quasi governmental) - Community Behavioral Health unique model in the country Began in 1997- 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
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
The Current Fiscal & Service Environment
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
HealthChoices Enrollment and Utilization History Monthly Enrollment 490,000 470,000 450,000 430,000 410,000 390,000 Clients Receiving Services 120,000 100,000 80,000 60,000 40,000 370,000 350,000 Enrollment Clients 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20,000-2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Proj. Enrollment 366,307 382,725 407,640 412,176 411,148 415,188 428,421 449,716 471,540 470,159 464,941 % 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 99,078 104,458 108,000 110,445 107,398 % of Enrollment 19.5% 19.8% 20.3% 20.9% 21.2% 22.2% 23.1% 23.2% 22.9% 23.5% 23.1%
Clients 120000 110000 100000 90000 80000 70000 60000 50000 Total Medical Expenditures Clients Amount Paid 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Amount Paid $ 750000000 $ 700000000 $ 650000000 $ 600000000 $ 550000000 $ 500000000 $ 450000000 $ 400000000 $ 350000000 $ 300000000 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Proj. Clients 71,552 75,859 82,709 86,336 87,155 92,114 99,078 104,458 108,000 110,445 107,398 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
The Political & Economic Climate Photo source: http://money.usnews.com/money/personal-finance/articles/2013/09/17/anniversary-of-the-great-recession-whats-changed-and-what-hasnt
The Transforming Environment
The Transforming Environment Philadelphia systems transformation The Affordable Care Act Opportunities Challenges Preparation Data considerations
Philadelphia Systems Transformation Courts Child Welfare Schools
The Affordable Care Act Unprecedented opportunities & challenges for behavioral health
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
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
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
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
Medicaid Expansion & Healthy PA
Prevalence of Behavioral Conditions Among Medicaid Expansion Population: Pennsylvania, US 25% Uninsured Adults Ages 18-64 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% - 19.7% U.S. CI: 14% - 15.9% Sources: 2008-2010 National Survey on Drug Use and Health (Revised March 2012) 2010 American Community Survey Substance Use Disorder PA CI: 11.4% - 23.2% U.S. CI: 13.2% - 15.2% CI = Confidence Interval Presentation by Kevin Malone, SAMHSA, HHS, May 2013
Preparing for Health Reform
DBHIDS & CBH Health Reform Priority Areas Eligibility & Enrollment/ Medicaid Expansion Integrated Care Models Health Information Technology/Reporting Workforce Development Essential Health Benefits/ Parity
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
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
DBHIDS Resources DBHIDS Public Health Policy & Planning Resources on dbhids.org Social media twitter @PhillyRecovery Publications Monthly Newsletter Bimonthly Policy Update Upcoming events & trainings Regulations database Information requests to shannon.mace@phila.gov
Health Reform Resources Healthcare.gov Localhelp.healthcare.gov http://kff.org/health-reform/ http://www.healthreformbeyondthebasics.org/ http://www.phlp.org/home-page/reform healthreformgps.org
Questions?
Thank you! Joan.Erney@phila.gov