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HomeMy WebLinkAbout034 18 .1 711 RESOLUTION No. 34-18 WASHI MGT.4i RESOLUTION NO. 129 -2018 Salish Behavioral Health Organization-Integration Pilot Whereas the State of Washington's vision for full financial integration of health care is within Managed Care Organization by January of 2020, therefore eliminating county behavioral health organizations and ceasing the accountability and oversight of local authorities in the planning and management of behavioral health care in the region; Whereas it has been a long-held value of Kitsap, Jefferson and Clallam Counties that, if possible, behavioral and physical health care should be delivered locally; Whereas the unique geographic areas within the Salish BHO region have distinct community based nonprofit behavioral health providers, hospitals, and health clinics working with the vast majority of the region's Medicaid clients; Whereas the geographically isolated Salish BHO region is connected by more ferries than roads to the rest of the state, the provider community has long standing linkages and relationships that facilitate strong community collaborations and the coordination of care central to improving consumer focused, whole person care; Whereas there are significant benefits to having local oversight and accountability of behavioral health care services and outcomes; Whereas the Salish BHO region has been a leader in the planning necessary to bring on new innovative programs, including integrated care, to address behavioral health needs; Whereas the Salish BHO maintains strong relationships between health and behavioral health providers throughout the Region; and WHEREAS: The Salish BHO supports continuing its long-standing practice of full clinical integration of behavioral health services; now, therefore, be it Resolved, that the Clallam County Board of Commissioners, Jefferson County Board of Commissioners, and the Kitsap County Board of Commissioners join the Salish BHO Board of Directors requesting the Washington State Legislature to create a legislatively approved pilot region in a geographically isolated area that provides for the clinical integration of Medicaid behavioral and physical health care services without full financial integration; and, be it, further Resolved, that the pilot project shall, (1) measure the effect of maintaining separate funding streams for Behavioral Health Organizations and Managed Care Organizations on the overall clinical integration of care; (2) use standards for measuring clinical integration that shall be negotiated between the HCA, the existing BHO, and partnering MCOs and that are comparable to fully integrated regions; (3) provide annual detailed analysis of its ongoing integration efforts; and (4) be terminated at the end of 2024, should the region be comparatively unsuccessful in its service delivery and outcome levels. t PASSED AND APPROVED on this ,P '. riday ofJ� 2018 BOARD OF COUNTY COMMISSIONERS JEFFERSON COUNTY, WASHINGTON p '„ rz''''..'./,:,` ?AKATE D AN, Commissioner, Dist. 1 t` - r itC Ye a. 4t I urLaolA-.4<62, KATHLEE LER, ommissioner, Dist.3 ,,, ..ei-'1 ..4 ",' //i/ ,./. 1-4-1/1 DAVI SULLIVAN, Commissioner, Dist.a ATTEST: edtk. 40,,, GCaroallaway, Dept* Clerk of the Board PASSED AND APPROVED on this Q (o day of cZ-1/4•�r-1 C , 2018 BOARD OF COUNTY COMMISSIONERS CLALLAM COUNTY,'WASHINGTON RAN'Y J� �j - .N Commissioner MARK OZIAS,t4 missioner (co--2.6-19 BILL EACH, Commissioner ATTEST: 40)\-)1 , Clerk of the oard PASSED AND APPROVED on this day of J L4 Lj , 2018 BOARD OF COUNTY COMMISSIONERS KITSAP COUNTY, WASHINGTON --a•O C' r /pP�• STAT*. its AO 4•( � ROBERT GELDER, Chair � .* 4 71.:0 % 0) .•NGTON:•.S.--CV EDWARD E. W' FE, Commissioner CHARLOTTE GARRIDO, Commissioner A I EST: / Dana Daniels, Clerk of the Board Regular Agenda JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERS AGENDA REQUEST TO: Board of County Commissioners Philip Morley, County Administrator FROM: Vicki Kirkpatrick, Director Jefferson County Public Health DATE: July 23, 2018 SUBJECT: DISCUSSION and POTENTIAL ACTION re: RESOLUTION for Salish Behavioral Health Organization (BHO) Request to Create an Integration Pilot to the Washington State Legislature STATEMENT OF ISSUE: The Board of County Commissioners will consider a proposed Resolution that has been submitted by the Salish Behavioral Health Organization (Salish BHO) in support of creating a pilot for the clinical integration of Medicaid-funded behavioral health and physical health. Clallam and Kitsap Counties have already adopted the Resolution. At the July 9, 2018 Board of County Commissioners heard a presentation by the Administrator of the Salish BHO and comments from the Jefferson County Public Health Director, the CEO of Jefferson Health Care, and a representative from Discovery Behavioral Health. At the conclusion of the presentation and comments, the Board of County Commissioners decided to postpone acting on the Resolution requesting more information and further opportunity to discuss the potential impacts of the proposed pilot. Vicki Kirkpatrick, Director, Jefferson County Public Health will make a presentation. Dr. Locke, Jefferson County Health Officer will provide comments. Anders Edgerton, SBHO Administrator will be there to respond to questions. Additionally, a representative from a Managed Care Organization will also be available to comment or respond to questions from the Board ANALYSIS: Each of the three counties covered by the Salish BHO have been invited to join the Salish BHO Board of Directors in requesting the Washington State Legislature to create a legislatively approved pilot region in a geographically isolated area that provides for the clinical integration of Medicaid behavioral and physical health care services without full financial integration; and, that the pilot project shall, (1) measure the effect of maintaining separate funding streams for Regular Agenda Behavioral Health Organizations and Managed Care Organizations on the overall clinical integration of care (basically maintains the status quo within the Salish BHO region); (2) use standards for measuring clinical integration that shall be negotiated between the HCA, the existing BHO, and partnering MCOs and that are comparable to fully integrated regions; (3) provide annual detailed analysis of its ongoing integration efforts; and (4) be terminated at the end of 2024, should the region be comparatively unsuccessful in its service delivery and outcome levels. The decision that the Board of County Commissioners will be making will determine the direction of the provision of mental health and substance use disorder services in Jefferson County. Attached to this Agenda Request is the proposed Resolution for Board consideration. FISCAL IMPACT: There is no fiscal impact from the Resolution itself, but a pilot may have impacts on the amount and use of Medicaid funding in all three counties in future years. RECOMMENDATION: Continue the discussion and consideration of whether or not to approve Resolution No. regarding the Salish Behavioral Health Organization (SBHO) Request to Create an Integration Pilot to the Washington State Legislature. REVIEWED BY: / , �� / g' /fir Mark McCauley, '1ng County Adminis'l0.r Date PRESENTATION TO THE JEFFERSON COUNTY BOARD OF COMMISSIONERS MONDAY,JULY 23, 2018 SALISH BEHAVIORAL HEALTH ORGANIZATION PILOT PROJECT PROPOSAL TO CONTINUE CURRENT ORGANIZATIONAL STRUCTURE AND KEEP FINANCIAL AND CLINICAL INTEGRATION OF PHYSICAL HEALTH CARE AND BEHAVIORAL HEALTH CARE SEPARATE RATHER THAN THE CURRENT REQUIREMENT TO EFFECT FULLY INTEGRATED MANAGED CARE BY JANUARY 1, 2020 BACKGROUND The Healthier Washington Initiative, developed through innovation grants from the Center for Medicaid and Medicare Services (CMMS/CMS), was designed to transform the health care system in Washington beginning with the State Medicaid System. The impetus for the change was the continually increasing cost of health care and the burden that places on the State budget and the lack of improved health outcomes resulting from the health care dollar spent. The general consensus has been that the health care systems (including behavioral health) are broken. While the U.S. spends significantly more than any other first world country, our health outcomes are dismal by comparison and the trend does not show improvement. The ever increasing cost together with poorer health outcomes has led many states to seek Waivers to allow changes in health care delivery systems in hopes of bending the cost curve and improving health. Washington is one of those states. The Healthier Washington Initiative was designed to achieve three primary objectives: Better health, better care at lower cost—often referred to as the Triple Aim. The transformation plan was designed by a coalition of health leaders from various health sectors and vetted by health care organizations, behavioral health organizations as well as public health jurisdictions, local governments, health oriented foundations, community based organizations that provide services that address the social determinants of health, and many other sectors. On top of that extensive review and input, the Initiative was also out for public comment. Once the design process was complete,the Health Care Authority applied for an 1115 Waiver through CMS. The 1115 Waiver is required whenever a state decides to try doing something different than the current standard Medicaid program provisions. A cornerstone of the Washington State 1115 Waiver was the implementation of a statewide Fully Integrated Managed Care system. The first step in integration was the incorporation of substance use disorder funding and clinical care into the Regional Support Networks under a new name: Behavioral Health Organizations (BHOs). That integration was fully implemented in April 2016. The second phase of accomplishing Fully Integrated Managed Care is the incorporation of all Medicaid services into managed care programs operated by Managed Care Organizations except for crisis services and non-Medicaid services rather than having two separate managed care service delivery organizations—one for health care and one for behavioral health (which is what we currently have). The fully-integrated model is intended to provide for person-centered service delivery and utilization of a medical home and care management that considers the full scope of the needs of the client including community supports such as housing, education, and other social determinants of health. The three domains of the Health Care Transformation 1115 Medicaid waiver hope to achieve better health, better quality, at lower cost. BHOs currently are responsible for serving the most chronically ill individuals—about 10%of the Medicaid population who meet the Access to Care Standards. If a client has a mental health issue, but does not meet the access to care standards,that person cannot receive Medicaid mental health services from providers contracted and paid by the BHOs. Per the Health Care Authority, the "current system for Medicaid clients are split between a BHO for behavioral health needs, and a managed care organization for medical needs. There is no single point of accountability for the client. For the HCA, integrated managed care is first and foremost about improving health outcomes and client care, and the HCA believes this requires care management though a single accountability insurance plan for the client—not two." Page 1 of 10 An example used by the HCA: "a client may be depressed and approach the BHO system for help but does not meet the Access to Care Standards. They don't know who to turn to for help. On the other side, people with serious mental illness have an average lifespan 25 years shorter than those without, and the reason for this is lack of access to medical care to treat the chronic illnesses arising from lifelong need for psychiatric pharmaceuticals. Integrated managed care seeks to improve the current system by placing a single insurance plan accountable for the full array of physical and behavioral health services and health outcomes." The HCA goes on to say: "Under the current system, as clients move around the state,the accountability for their health outcomes could transfer across 14 entities: nine BHOs and five MCOs. When integrated managed care is in place, this will be reduced to not more than five and no more than one at a time. A frequently asked question published by the HCA(See handout entitled "Why change Apple Health to an integrated Managed Care Model?") is "Counties currently have authority over the behavioral health deliver system because county commissioners sit on the BHO board. How will county authorities be able to respond to calls from constituents to fix problems in the system? Answer from HCA: "The transition to integrated managed care does not mean there is no role for the county. Counties will pay a significant role, even though they are not the direct contract holder or are not at direct financial risk for providing behavioral health services. Counties will have the ability to shape their role HCA is willing to report to any entity chosen by county officials to ensure effective county involvement." Additionally, "The counties have the first right of refusal to act as the Behavioral Health Administrative Service Organization (BH-ASO). The BH-ASO delivers crisis services, administers certain non-Medicaid funding sources, and manages regional functions, such as employing an ombudsman and managing a community behavioral health advisory board. Additionally, the MCO contracts require that the MCO coordinate with county-managed programs, criminal justice, long-term supports and services,tribal entities, etc.via an Allied System Coordination Plan. This will ensure that those established relationships continue to stay strong as well as encourage the MCO to establish necessary relationships. See attachment: "Options for Behavioral Health Services Responsibility in Integrated Managed Care" for possible county options. ISSUE The Salish BHO is requesting that the Board of County Commissioners support legislation that would establish a "carve out"for a pilot project that would allow the Salish BHO to continue to operate as it does currently which maintains the bifurcated funding system that currently exists with the BHO Medicaid funding mental health and substance use disorder services and the Managed Care Organizations funding Medicaid physical health services. The goal would be to accomplish clinical integration while maintaining two separate funding streams and two separate insurance organizations. The pilot would request the Washington State Legislature to create a legislatively approved pilot region in a geographically isolated area that provides for the clinical integration of Medicaid behavioral and physical health care services without full financial integration; and,that the pilot project shall, (1) measure the effect of maintaining separate funding streams for Behavioral Health Organizations and Managed Care Organizations on the overall clinical integration of care; (2) use standards for measuring clinical integration that shall be negotiated between the HCA,the existing BHO, and partnering MCOs and that are comparable to fully integrated regions; (3) provide annual detailed analysis of its ongoing integration efforts; and (4) be terminated at the end of 2024, should the region be comparatively unsuccessful in its service delivery and outcome levels. The decision that the Board of County Commissioners will be making will determine the direction of the provision of mental health and substance use disorder services in Jefferson County. Page 2 of 10 Possible Impacts to Choice Options Issues/ SBHO Pilot Fully Integrated Managed Care Comments/ Considera- Concerns Questions tions Current Law Requires a Legislative Meets requirements of current law. Is there a clear, Change. Contrary to factual, and State 1115 Waiver compelling reason that requires FIMC to deviate from statewide. Potential statewide plan? risk to 1115 Waiver. Risk Counties, directly Managed Care Organizations carry the If the SBHO and through the BHO risk for MH/SUD services except for became an ASO, carry the risk for those services provided by the ASO the Counties would Medicaid behavioral just like they do for medical care retain the ability to health services in oversee and direct Jefferson County the use of the non- Medicaid funds, and the crisis services that impact the ED,jail, EMS, law enforcement along with the risk they currently carry. Certainty Extends the All local entities are on the same Could uncertainty /uncertainty uncertainty of timeline for FIMC—Effective no later lead to potential whether or not than 1/2020. system instability Jefferson County in Jefferson County providers will be and what impact required to engage in does it have on the FIMC to 2024. work that Jefferson Impacts how local Health Care has entities engage. undertaken to effect full integration within their health care system? Lack of Trust in Preserves existing MCOs will contract with providers and There is a What Managed Care system and existing will be held to certain perception that services are and For Profit quality standards standards/metrics related to improved there is a general currently Insurance through at least 2024 health. lack of services for provided Companies. the Medicaid through the Whether or not population within BHO in Access to Care Jefferson County— Jefferson Standards remain in particularly crisis County that place for the SBHO related services would not during the pilot and innovative/ be provided period is unknown. Under the MCO model, providers will evidence-based or likely lost negotiate rates with the MCOs. programs. if provided Whether or not that means fewer Page 3 of 10 funds for local Medicaid providers is So the defined through the not known. network of MCO? MH/SUD providers and programs housed within Jefferson County continues to be an issue/concern whether the insurance provider is the SBHO or the MCOs. Availability of services to Jefferson County residents from programs and providers in other counties does not always mean they are accessible to Jefferson County residents so network adequacy needs to ensure that services are truly and equitably accessible to Jefferson County residents. Care for the Under the current If the MCOs contract with providers How effectively a The data most system the that provided services through the BHO or a MCO thus far in chronically inappropriate use of BHO,then those providers are bring services to SW acute mentally the hospital experienced in treating these most those Medicaid Washington ill and/or emergency vulnerable clients—many of whom are eligible clients can, (the early substance use department, the jail homeless, unemployed, etc. in one way, be adopter for disorder beds used measured by their FIMC) residents and disproportionally for penetration rate— shows an concern that those suffering from how many of those increase in for profit mental illness and/or in need of services penetration insurance substance use are receiving rates in companies will disorder exists today. them? both MH not serve them These are often the and SUD. appropriately most difficult of our or adequately residents suffering keep them from severe engaged in behavioral health health care and issues to treat. behavioral health services. Page 4 of 10 Some of our most vulnerable and difficult residents to get and keep in treatment services and who often frequent the hospital emergency department and our jail and consume much of our law enforcement, EMS, and criminal justice system will fall through the cracks under an MCO model. Concern that Preserves existing MCOs are held to stringent quality If Access to Care MCOs will system through at standards under their contract with Standards remain provide less least 2024. BHO has HCA and providers are also then held in place for the quality quality standards to those standards. SBHO during the services. providers are pilot period, will expected to meet. Removal of access to care standards that mean that give the providers the ability to serve Medicaid eligible Will Access to Care any client who comes through their clients who do not Standards remain in doors, regardless of their level of need meet those place for the SBHO giving more clients the opportunity to standards lack during the pilot? receive services. access to behavioral health services? Concern that One of our region's MCOs, MCOs will Amerigroup, stated that access to establish behavioral health care on a managed, barriers to regular basis actually helps the MCO behavioral contain cost of other more expensive health services services, like ER visits or crisis care. in order to Their goal is to remove barriers to contain cost accessing BH services. To that end, Amerigroup does not require authorizations for outpatient mental health services (regardless of level of need or for specialized services like PACT and WISE). Page 5 of 10 Concern that A representative from Amerigroup MCOs will push states that getting to a point where a people out of member/client's BH condition is treatment managed is what contains cost. before they are Amerigroup encourages as much ready in order treatment as possible, even ongoing to contain or treatment and therapeutic reduce cost management, so that a client does and increase feel support in managing their BH profit conditions. That should result in less ER or hospital visits if BH conditions are managed. Additionally, once a member/client feels like they have more management over their BH condition,they will more likely seek primary care to manage other potential physical health co-conditions they may be experiencing. The MCOs are profit-limited per the contract with the HCA and CMS requirements. At most they can retain approximately 3-5%of cost-savings as profit. Any cost savings beyond 5% is returned to the state and federal government. Per the Amerigroup representative, the profit they do retain is largely invested back into the community,their staff, and taxes. Some of the profit does go back to Anthem. Concern that The integrated model being developed fully integrated and implemented by Jefferson Health managed care Care includes having licensed BH staff will result in and providers accessible or embedded behavioral in primary care so that the client's BH health services conditions or treatment can be being taken diagnosed/planned for with the client over by by an appropriate BH provider.The medical care right administrative structures and services and workflows need to be in place that clients will internally to allow for communication be prescribed between the medical and BH medication to providers for a whole person address their treatment plan that addresses both mental illness their BH and physical health needs— and other patient centered. therapy will be de-emphasized Page 6 of 10 Concern that The HCA contract with the MCOs Network adequacy network will be includes network adequacy is a current inadequate requirements for primary and concern regardless specialty or higher need service of who is paying for providers for both physical and the services. behavioral health. If they fail to meet Jefferson County those requirements or lose their has experienced ability to meet those requirements, and continues to they can no longer have membership experience lack of within that county. access to mental health services and medication assisted treatment for SUD clients on Apple Health. The current Medicaid mental health provider continues to experience some instability. The current system has not resulted in financial stability for the Medicaid Mental Health provider in Jefferson County Concern that The representative from Amerigroup For crisis services, MCOs will drive states that driving small, local the provider will small, local providers out of business is never their need to negotiate providers out goal. If a provider is willing to accept with the ASO for of business and and treat Medicaid clients,they those rates. pay them less welcome conversations with that than BHO pays provider to join their network. In those conversations, it gives the small providers an opportunity to negotiate the rates that they want and need to adequately serve Medicaid clientele. Amerigroup has been starting with the structure the BHO pays for Medicaid and replicating or building on it for the providers coming into managed care. How does Does the SBHO have With accountability for both the clinical a plan for achieving finances and clinical physical and integration fully integrated behavioral health services through happen under clinical managed care their provider contracts, MCOs can each scenario? that includes ensure clinical integration through accountability for their contracts with both behavioral whole person care? and physical health providers and Page 7 of 10 ensure care coordination and management through accountability requirements built into their contracts with providers just as the MCOs are held accountable for full clinical integration through their contract with the HCA. What are the No change under the If Jumping Mouse is a Medicaid To continue to be impacts on current system. provider for children's mental health eligible to provide Jumping services,they can opt to become part Medicaid Mental Mouse? of the MCO network of providers. Health Services for any mental health and SUD provider either through the SBHO or the MCOs, integration becomes a requirement. What is not yet clear is whether or not Jumping Mouse would be seen as a specialty Children's MH service. Either way, the impact may be the same under either the SBHO or the MCO. What are the Medicaid does not Medicaid does not pay for MH or SUD Currently impacts on the pay for MH or SUD services while someone is supportive services Jail? services while incarcerated. in the jail are someone is provided through incarcerated. the 1/10 of 1% funds. Funding is needed for other evidence-based services while people are in the jail (such as access to medication assisted treatment and other therapy services). Once released from jail, individuals eligible for Medicaid can receive treatment services under either scenario. Case/care Page 8 of 10 management beginning in jail and continuing upon release is needed. Impacts on Criminal Justice Clients of the Therapeutic Courts who Therapeutic Treatment Act (CJTA) are sent for MH or SUD treatment are Courts funding is contracted referred to provides for that service through the BHO and and if they are Medicaid eligible, is used to help Medicaid can cover the costs for those support certain services. services for the Therapeutic Courts Presumable CJTA funds would continue to be provided from the Clients of the State either through the ASO or Therapeutic Courts directly to the County. who are sent for MH or SUD treatment are referred to providers for that service and if they are Medicaid eligible, Medicaid can cover the costs for those services. Jefferson Currently the health Again, while not knowing exactly how County Public department bills the health department clinical services Health Clinical Medicaid eligible would be classified under the MCO Services clients as an fully integrated model,the health (Family independent clinical department currently bills the MCOs Planning, provider. in Jefferson County for clients who are School-Based on Apple Health. In the School-based Health Clinics, Because the services clinics, the clinicians meet regularly and are not primary care with the mental health counselors Immunizations) services the clinical provided to the schools through the services provided by 1/10th funding. the health department would The health department clinicians refer likely be classified as clients for mental health and/or specialty services. It substance use disorder services when is unclear how initial screening indicates the need. clinical integration under the Pilot Without Access to Care Standards, Proposal would access to Mental Health Services for affect the health Medicaid Clients may be easier. department if at all. Currently the health The health department does not know department refers what fully integrated clinical services clients to MH/SUD may mean for our limited clinical providers if their services. basic assessment indicates the referral Page 9 of 10 is appropriate. If they have Apple Health and don't meet the Access to Care Standards, access to services is difficult. Finally, you as the Legislative Body for Jefferson County are being asked to make a tough decision and to try and figure out which decision is best for the residents of Jefferson County. It's not so much about a right or wrong decision, it's more about what is best for our folks here in Jefferson County. This is a Legislative ask that you are being asked to support. It's a heavy lift to ask the State Legislature and the Governor to support a proposal that does not have the support of the State Agency responsible for the Medicaid system state-wide. The SBHO system is familiar and one in which you have some direct control. The Fully Integrated Managed Care system through the Managed Care Organizations is new and it is the path chosen by the State of Washington and approved by CMS through the 1115 Waiver to achieve the goal of better care, better health, and lower cost. Similar Medicaid programs have been put into place in other State with some success in achieving the goals. Is this the best way to go or the right way? We don't know and won't know until we are able to gather data over time and measure whether or not the State is achieving its goals. Most would agree that the current health care system is broken and the Healthier Washington Initiative requiring health care transformation through the full integration of behavioral health and physical health with the Managed Care Organization holding both the risk and the accountability is a cornerstone of the transformation. This together with the requirements and oversight expectations of the Accountable Communities of Health are expected to yield the desired results. We have our single largest health care provider supporting continuation of current HCA timeline for fully integrated managed care rather than further delaying implementation to 2024 and continuing the uncertainty that comes with that for their business. The things identified by the SBHO Administrator that the SBHO has done in the last few years or are involved in now are good things, but except for the funding to train JHC physicians for certification to initiate Medication Assisted Treatment (MAT)which happened because Jefferson Health Care has been committed to providing MAT in Jefferson County and some work with OlyCap on housing, most of the services are outside of Jefferson County. The treatment services provided through the BHO will continue to be provided under the MCOs. It is my opinion and belief that in Jefferson County(which is different than the circumstances in both Kitsap and Clallam in relation to SBHO funded projects and programs)we will not see a difference for our residents if we move forward with FIMC under the MCOs and we will remove the extended uncertainty which concerns and impedes the progress of our health care partner and largest provider. I also believe it is a long shot that the State Legislature and the Governor will support this pilot proposal so you are left with the question of where you spend your political capital in Olympia on behalf of the residents of Jefferson County. Page 10 of 10 T C fD -I () O 'p —• _ 0- O O O N Oq V1 v a 0 0 = O (D SI d fD 0 Q- O °' = ^ 0- '� ? < au ,� 0 e' S' C fD CD N D -q N y V Q. F.. rr• "r=71-2, o O a 0 a. Q 3 g V mcj CO (f) –S 0) -t (Da. Eo E CDC . a) O v, n n , m K � 3 0 °3 G 0 o CD Q o rD o fl CDa n fD �, 3 n- :-." 0 a _ �. A S K . 0 o E � 3E z LO O = 7 no- 7 O 0 ` ) CO 2 nCU < 0 v, E 3 ^ n `D a N fD CI O v n •- c X Q 0i 7 6 co O- 3 0) - _ c -, "6_ ....„.°) n CD on r, -0 : u, a.v $ o <, 0 -n —I 9 5- rr3o EY r, G CD n < < NO 4 = n 7 7 7 _. a O v, .0.�, <. 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Under the behavioral health organizations (BHOs) there is a single point of accountability and oversight for behavioral health services in every region, so how could it be better to divide accountability among as many as five entities? Answer: Today,benefits for Medicaid clients are split between a BHO for behavioral health needs,and a managed care organization(MCO)for medical needs.There is no single point of accountability for the client. For the state Health Care Authority(HCA),integrated managed care is first and foremost about improving health outcomes and client care,and this requires care management through a single accountable insurance plan for the client—not two. For example, a client may be depressed and approach the BHO system for help but does not meet the Access to Care Standards.They don't know who to turn to for help.On the other side,people with serious mental illness have an average lifespan 25 years shorter than those without,and the reason for this is lack of access to medical care to treat the chronic illnesses arising from lifelong need for psychiatric pharmaceuticals. Integrated managed care seeks to improve the current system,by placing a single insurance plan accountable for the full array of physical and behavioral health services and health outcomes. Under the current system,as clients move around the state,the accountability for their health outcomes could transfer across 14 entities: nine BHOs and five MCOs.When integrated managed care is in place,this will be reduced to no more than five and no more than one at a time. Counties currently have authority over the behavioral health delivery system because county commissioners sit on the BHO board. How will county authorities be able to respond to calls from constituents to fix problems in the system? Answer: The transition to integrated managed care does not mean there is no role for the county.Counties will play a significant role,even though they are not the direct contract holder or are not at direct financial risk for providing behavioral health services.Counties will have the ability to shape their role. For example, Southwest Washington created a Regional Advisory Council,which is comprised of county commissioners and state legislators, and meets twice a year with the state,MCOs and the public to evaluate the effectiveness of service delivery in the region. HCA is willing to report to any entity chosen by county officials to ensure effective county involvement. What role will the BHO have after integrated care is implemented? Answer: The counties have the first right of refusal to act as the Behavioral Health Administrative Service Organization(BH-ASO).The BH-ASO delivers crisis services,administers certain non-Medicaid funding sources, and manages regional functions,such as employing an ombudsman and managing a community behavioral health advisory board.Additionally,The MCO contracts require that the MCO coordinate with county-managed programs, criminal justice,long-term supports and services,tribal entities, etc.via an Allied System Coordination Plan.This will ensure that those established relationships continue to stay strong as well as encourage the MCO to establish necessary relationships. For more information on the role of the BH-ASO and county options,HCA has developed a document outlining a possible continuum of county options. FAQs produced by the Washington State Health Care Authority,April 2017 v.2 i Is the state planning to implement the same model statewide that was developed in Southwest Washington? Answer: No.The Southwest Washington model is not the only model. In mid-adopter regions, HCA is open to discussing regional variations and options with communities.The first step in that discussion is to submit a binding letter of intent to move forward with full integration before 2020. BHOs are non-profit organizations. Won't this transition to managed care health plans result in less funding for a behavioral health system that is already under-funded? Answer: Apple Health contracts strictly limit administrative overhead to population enrollment.The range of administrative load is 8.5 percent to 11.8 percent in 2017. The contract limits the gains MCOs are able to take from premium dollars. How do we know that funding for behavioral health services won't be diverted to pay for medical care, once the funds for medical and behavioral health services are blended together and the MCOs are working under a global budget? Answer: There are a number of reasons this will not be an issue: • The managed care contracts require the MCOs to provide certain behavioral health services and meet certain performance measures and quality of care standards. In order for the MCOs to provide these services and meet performance measures and quality standards,they must invest in behavioral health services. • If a client's need for services meets level of care guidelines and is medically necessary,the MCO must ensure the client receives the behavioral health services. • When managing a global budget,MCOs have incentives to invest in downstream services such as primary care and outpatient behavioral health,in order to meet performance measures and to achieve savings on high-cost upstream services such as emergency room visits. • Behavioral health providers negotiate their payment rates and payment method with the MCO and should expect to be paid no less than what they are paid in the current BHO structure. How will the managed care plans develop the needed competence to manage these complex services? Answer: MCOs are already familiar with clients with serious mental illness and substance use disorder.These clients are among their most complex enrollees, and they currently provide care coordination,complex case management,and health home services to this high-risk population.What will require a knowledge transfer period is for the MCOs to learn the new provider network,service delivery,etc.that has been provided through the BHOs. HCA and Division of Behavioral Health and Recovery(DBHR)staff stand ready to assist with this knowledge transfer as MCOs are awarded contracts. The project described was supported by Funding Opportunity Number CMS-1G1-14-ool from the U.S.Department of Health and Human Services,Centers for Medicare&Medicaid Services.The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. Counties already spend a high percentage of their budgets on their jails. If this transition reduces access to behavioral health services, individuals in need of treatment may end up in the county jail rather than in treatment. How do we monitor for this and make sure this transition does not increase the burden on jails? Answer:There is no reason to expect reduced access to services for people in need of behavioral health treatment. In fact,the transition to integrated care is intended to improve the delivery of medical and behavioral health services,which may result in reduced incarceration of individuals with behavioral health conditions.To help ensure this happens,the Health Care Authority will work with counties to develop an"early warning system"that will track flow into the local criminal justice system.And the state's contract will require MCOs to outline their best practice models for assisting with clients in transition. This transition to integrated managed care seems to be focused on financial and contracting integration, not on clinical integration. How will the transition to integrated managed care support delivery system reform at the clinical level? Answer:Integrated managed care is necessary but not sufficient to achieve clinical integration. By integrating the way the state purchases and administers medical and behavioral health services,this sets a foundation for managed care plans and providers to work towards integration at the delivery system level. For example: • Physical and behavioral health providers will be contracted with the same payers, and can negotiate payment for integrated clinical services with those payers.This does not exist in the current bi-furcated payment system. • Integrated MCOs will cover all services and bring a patient's health information and history to one source. This model makes it easier to share information between service providers so providers have a whole-person view of the patient and better understand what services the patient does/does not need. This more seamless sharing of information will facilitate coordination and collaboration between different provider types,thus promoting integration at the clinical level. • MCOs will assist with client care coordination across the full continuum of services,so that care coordination and care management activity is not bi-furcated across multiple entities for a single client. • MCOs will have a full network of both medical and behavioral health providers,which will allow them to facilitate referrals across provider types. • Additionally,the recently approved 1115 DSRIP Waiver will complement the transition to integrated managed care,by making significant regional investments in integrated clinical models. Is the state really going to be able to meet the January 1, 2020 deadline that was set in legislation E2SSB 6312? Answer:Yes. All counties will operate in an integrated managed care model by January 1, 2020.