health and human services transformation · identified on the basis of a claim with a behavioral...

Health and Human Services Transformation

Medicaid Waiver Advisory Council

Behavioral Health Transformation

May 23, 2018

DRAFT Confidential – Proprietary and Pre-decisional 1

FY2015 members and spend1,2

Medicaid individuals with diagnosed behavioral health needs make up ~25% of the population, but ~56% of the total spend

44%

48%

8%

7%6%

62%

25%

0%

Individuals with diagnosedbehavioral health needs5

Spend

10.53.1

Members

Medical spend4

Behavioral health core spend3

Individuals with only carecoordination fee spend6

Spend for non-behavioralhealth members

Individuals with no claims

Individuals with no diagnosedbehavioral health needs5

100% =

Spend for members with onlycare coordination fee spend6

1 Annualized members (not unique members) shown here with no exclusions made on population or spend. Annualized member count = Sum of member months/12 2 Most inclusive definition of behavioral health population used here of members who are diagnosed and treated, diagnosed but not treated, and treated but no diagnosis

present. Behavioral health core spend defined as all spend with a behavioral health primary diagnosis or behavioral health-specific procedure, revenue, or HIC3 pharmacy code.

3 Behavioral health core spend is defined as spend on behavioral health care for individuals with behavioral health needs4 Medical spend is defined as all other spend for individuals with behavioral health needs. See appendix for additional methodology notes5 Behavioral health diagnosis is defined as a behavioral health diagnosis in any of the first 18 diagnosis fields of any claim during the year. Behavioral health treatment is

identified on the basis of a claim with a behavioral health primary diagnosis or a behavioral health-specific procedure, revenue, of HIC3 drug code during the year6 Annualized members with only spend for care coordination fees. Care coordination fee is identified by HCPCS codes - G9002, G9008

Annualized members (millions), dollars (billions)

SOURCE: FY15 State of Illinois DHFS claims data


Behavioral healthcore spend

109

Medical spend

11294988483

157

121387

80829087

8483

5581778784 86

90

36100

Each bar represents5% of customers: ~18K customers

Distribution of Medicaid behavioral health primary population1 by behavioral health core spend rank

Total spend = $2,550M

5% most costly customers bybehavioral health core spend

5% least costly customers by behavioral health core spend

In Illinois, the costliest 10% of Medicaid members account for 72% of behavioral health spend

SOURCE: FY15 State of Illinois DHFS claims data

The top 10% highest spend behavioral health customers account for:▪ 72% of core behavioral health spend▪ 30% of the total Medicaid spend of

the behavioral health population

1 Distribution of unique members shown here2 Primary population defined as Medicaid members with behavioral health needs minus those who have been treated but not diagnosed and those who have been diagnosed but not treated.

It also excludes those with dual eligibility or non-continuous eligibility or third-party liability, It also excludes those who died during their inpatient stays


Informed by stakeholders and customer archetypes, Illinois envisions a member-centric behavioral health system enabled by ten key elements

Data inter-operability

and transparency

High intensity assessment,

care planning, and care

coordination / integration

6

Low-intensity assessment,

care planning, and care

coordination / integration

7

8

Structure, budgeting, and policy

support

10

Integrated, digitized

member data

2

Enhanced identification, screening &

access

1

Best practice vendor and

contract management

9

The nation’s leading member-

centric behavioral

health strategy

Core and preventive behavioral

health services

3

Behavioral health support

services

4

Workforce and system

capacity

5


Rebalance the behavioral health ecosystem, reducing overreliance on institutional care and shifting to community-based care 1

Promote integrated delivery of behavioral and physical health care for behavioral health members with high needs2

Promote integration of behavioral health and primary care for behavioral health members with low needs3

Support the development of robust and sustainable behavioral health services that provide both core and preventative care to ensure that members receive the full complement of high-quality treatment they need

4

Invest in additional support services to address the larger needs of behavioral health patients, such as housing and employment services5

Create an enabling environment to move behavioral health providers toward outcomes- and value-based payments 6

Illinois has identified 6 goals it hopes to achieve through this waiverA


Other demon-strationgrants

1115waiver

Other waivers

Advance Planning

Documents

State Plan Amendments

General revenue

funds


STATE PLAN AMENDMENTS

DESCRIPTION PROPOSED EFFECTIVE DATE

Medication Assisted Treatment January 2017

Mobile Crisis Response Summer 2018

Crisis Stabilization Summer 2018

Uniform Child and Adolescent Needs and Strengths (CANS) and Adult Needs and Strengths Assessment (ANSA)

Summer 2018

Integrated Physical and Behavioral Health Homes October 2018


WAIVER PILOTS APPROVED

Description DY1 DY2 DY3 DY4 DY5

SUD/IMD X X X X X

SUD Case Management X X X X X

Withdrawal Management X X X X X

Peer Recovery Support Services X X X X X

Crisis Intervention Services X X X X X

Evidence-based Home Visiting Services

X X X X X

Assistance in Community Integration Services

X X X X

Supported Employment Services X X X X

Intensive In-Home Services X X X X X

Respite X X X


SUBMITTED WAIVER PILOTS NOT INITIALLY APPROVED

Description DY1 DY2 DY3 DY4 DY5

30 days pre-release Continuing to work with CMS

MH-IMD Not approved

Workforce Strengthening Initiative Not approved

First Episode Psychosis Continuing to work with CMS

Infant/Early Childhood Mental Health Interventions

Continuing to work with CMS

Behavioral and Physical Health Integration Activities

Withdrawn


WAIVER PILOTS

Description EligibilityGeographic Recipient

SUD/IMD X

SUD Case Management X

Withdrawal Management X

Peer Recovery Support Services X

Crisis Intervention Services X

Evidence-based Home Visiting Services X

Assistance in Community Integration Services X

Supported Employment Services X

Intensive In-Home Services X

Respite X


INTEGRATED HEALTH HOMES


Integrated Health Homes in Illinois are: Integrated Health Homes in Illinoisare NOT:

… and NOT on the provision of all services▪ Provider of all services for members▪ A gatekeeper restricting a member’s choice of

providers▪ A physical place where all Integrated Health

Home activities occur▪ A care coordination approach that is the

same for all members regardless of individual needs

Primary focus is on coordination of care…▪ Integrated, individualized care planning and

coordination resources, spanning physical, behavioral and social care needs

▪ An opportunity to promote quality in the core provision of physical and behavioral health care

▪ A way to encourage team-based caredelivered in a member-centric way

▪ A way of aligning financial incentives around evidence-informed practices, wellness promotion, and health outcomes

For members with the highest needs:▪ A means of facilitating high intensity,

wraparound care coordination▪ An opportunity to obtain enhanced match for

care coordination needs▪ Identifying enhanced support to help these

members and their families manage complex needs (e.g., housing, justice system)

What an Integrated Health Home is and is not


Managed Care Organizations

Payment streams, in response to Integrated Health Homes meeting requirements and improving outcomes

Higher-intensity Integrated Health Homes

Lower intensity Integrated Health Homes

Integrated Health Homes

Higher-needs population1 Lower-needs population1

1 Actual tiering of intensity of care coordination may not be binary

JaneBrice Mike Mia Stephen DarnellAshley Tom William JennGreg CynthiaConnorJerry

Population health

management

Member engagement

and education

Physical/ maternal

health provider

engagement

Behavioral health provider

engagement

Integrated care planning and monitoring

Supportive service

coordination

Reporting of quality and efficiency of care (i.e., member outcomes)

Enhanced access, screening, and assessment

Integrated Health Homes will deliver improvements in care delivery across a range of areas


Profiles of ACA Health Homes launched to dateIllinois would be the first fully integrated Health Home

Largest Medicaid Health Home programs developed as of February 2017

60

69

220

230

252

252

522

540 26%

26%

3%

19%

4%

3%

Number of enrollees, thousands

Many states also employ Patient-Centered Medical Home programs to coordinate the physical health needs of their members separately, but Illinois model would coordinate both physical and behavioral health care for all ~3.1m Medicaid members

Conditions addressed

▪ Chronic

▪ Chronic/SMI

▪ Chronic/SMI

▪ SMI

▪ Chronic

▪ SMI/SED

% of Medicaid population

1 Only includes members who are part of the state’s largest Health Home program 2 SMI = Serious Mental Illness; SED = Serious Emotional Disturbance

4%

4%

▪ SMI/SED

▪ Chronic

Includes members with SMI/SEDs1

SOURCE: CMS Health Home IRC


Principles for developing care delivery model

Develop a person- and family-centered care delivery model for the whole Medicaid population, regardless of match status, that encourages member and family engagement

Craft a flexible care delivery approach that reflects the diverse needs of members in Illinois and recognizes that member needs change over time

Evolve toward full clinical integration of behavioral, physical, and social healthcare

Acknowledge and accommodate geographical variation in provider capabilities, readiness, and priorities

Strike an appropriate balance between provider flexibility and accountability to enable capabilities and readiness

Prioritize economic sustainability of care delivery model at both the systemic and provider levels


Overview of potential approach to IHH member stratification

Level of physical health needs

Level of behav-ioralhealth needs

Low

High

High Low

High behavioral health needs,Low physical health needs

High-estneeds

Low behavioral

health needs, high physical health needs

Low needs members

Moderate needs members

ILLUSTRATIVE

Full Medicaid population will be included in the model, with exception of those receiving duplicative care coordination, in LTC facilities after 90 days, or with MMAI dual, partial eligibile, or TPL status

Approach to tiering adopted to ensure members with similar needs receive comparable care coordination support, and to focus resources on those members who need greatest support

A