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Public Affairs Consulting Contract


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									Finance, Policy and
Integration of Services

Mental Health America
Fall Policy Conference
October 15, 2008

Charles Ingoglia, MSW
Vice President, Public Policy
National Council for Community Behavioral
Elements of BH Integration
   Financial or structural integration does
    not assure clinical integration                         Clinical
   Clinical integration helps us focus on
    what consumers need
   Public sector efforts focused on
    financial integration (carve-ins) have
    had limited success
   Clinical integration requires financial
    and structural supports in order to be
    successful                                  Financial              Structural
   Public sector financing is a major
    barrier to achieving clinical integration   Behavioral Health/Primary Care
    in most settings                                     Integration
   Washtenaw County and Cherokee
    Health are outstanding examples of
    attending to all aspects of integration

New Freedom Commission Report
 Goal 5 - Excellent Mental Health Care Is Delivered and
  Research Is Accelerated
 The Commission recommends that Medicare, Medicaid, the
  Department of Veterans Affairs, and other Federal and State-
  sponsored health insurance programs and private insurers
  identify and consider payment for core components of
  evidence-based collaborative care, including:
   Case management
   Disease management
   Supervision of case managers
   Consultations to primary care providers by qualified
     mental health specialists that do not involve face-to-face
     contact with clients
Pilot Projects and Financing
 Aetna project provides financial support for the
  same service components proven in the IMPACT
  trials, identified in the RWJF sites and being
  tested in state Medicaid pilot sites:
    Screening
    Care management
    Psychiatric consultation (principally by telephone)
 These service components are currently missing
  from public and private sector billing codes and
  financing policy
 As pilots emerge for placing primary care
  capacity in mental health settings, similar “silo”
  barriers are being identified

MCPP Healthcare Consulting   5
Populations and Financing

           MCPP Healthcare Consulting   6
Safety Net Population Prevalence
 Medicaid Mental Health managed care penetration
  targets were set at 10% in the early 90s, based
  on a 7% rate in the commercial population—this
  has influenced financing levels for the public
  mental health system
 Emerging data suggests much higher prevalence
  in the Medicaid, General Assistance and uninsured
  populations and inability of the public mental
  health system to serve these populations

Safety Net Population Prevalence
              Washington     Washington     Colorado        Marrilac
                State          State         Access         Clinic
                                                         Grand Junction
Population   Medicaid Adults   General    Medicaid Adults Uninsured
              Aged, Blind,    Assistance (all aid codes)
               Disabled      Unemployable
Number         100,171         22,917         6,500         500

Any               47%           52%           40%             51%
MH/AOD          (claims)      (claims)      (claims)         (PHQ9)
Diagnosis                     MH-36%
                             AOD 32%
Percent          52%
                 Of those
                             MH-22.1%         33%
                                              Of those
Seen by          w/ Dx           -13.7%
                             AOD total
                                Of            w/ Dx
About the Public Sector BH
 Different delivery models in every state
   Community based non-profit agencies
   County operated agencies, either separate or in larger
      agency with public health
   State operated agencies, regional areas of
 Licensing and regulatory activity (documentation
  requirements, data dictionaries, etc.) also differs by state
   Most states have considerable paperwork
      requirements related to initial and ongoing service
      delivery (e.g., 20 page initial assessment and
      enrollment packets)
State Mental Health Funding
Comparisons, Fiscal Year 2001

This table compares state mental health funding (all sources, all services) for the
top 30 states and how each compares with the average of the top 10 states,
which can be considered a proxy for adequately funded states

About the Public Sector BH
 MH and SA administrative structures and relationships
  also differ (state, regional, county)
 Different Medicaid financing structures in every state
  (or county or region)
   Carved out (risk or ASO contract)
   Carved in
   FFS billing
 The principle use of State general funds for BH
   Medicaid match
   Coverage for low income uninsured
 Population focus varies (SPMI/SED, TANF)
More About the Money
 HRSA PIN 2004-5 clarifies that Medicaid agencies
  are required to reimburse FQHCs and RHCs for
  behavioral health services provided by physicians,
  physicians assistants, nurse practitioners, clinical
  psychologists, and clinical social workers—but there
  has been little action at the state level, especially in
  managed care states
 CPT codes for BH services in primary care (for a
  physical health diagnosis) have been adopted by
  Medicare, but little action by commercial insurers or
  Medicaid agencies—some states have adopted as the
  method for implementing PIN 2004-05
CPT Codes for Behavioral Health
Services in Primary Care (2004)

           MCPP Healthcare Consulting   14
Other Promising News About $
 New in 2008 are CPT codes (99366, 99367 and
  99368) for interdisciplinary team conferences.
   May be used to support team conferences that
     address complex co-morbidities
 DIAMOND program in Minnesota is the first
  depression treatment program in the nation to
  integrate a collaborative care model with an
  effective, sustainable reimbursement structure
   The DIAMOND financing approach covers care
     management and psychiatric consultation costs,
     and will be utilized by both public and private
     sector payors in a statewide initiative
   Paying for Treatment for Substance
   Use Screening in Primary Care
 Center for Substance Abuse Treatment has sponsored
  Screening and Brief Intervention (SBI) programs in 17
   Based on more than 30 controlled clinical trials that
     demonstrated the clinical efficacy and effectiveness of
   Screening and brief interventions for more than 424,000
     people across inpatient, emergency department, primary
     and specialty care settings, including CHCs
   Newly established series of Current Procedural
     Terminology (CPT) SBI codes provide a vehicle for billing
     SBI services (99408 and 99409)
 The Money and Implications for
 Public mental health systems are frequently under-
  funded to serve their target populations (for both
  numbers of people and amount of service), much less
  populations that are not SMI/SED
 Many states are reducing coverage of the uninsured
  in their public mental health systems
 Medicaid and uninsured (safety net) populations may
  have higher levels of MH/SA prevalence than the
  general population
 These safety net populations may also have higher
  utilization rates of ER and other healthcare services

The Money and the Business
 Financial models (FFS, case rates, global payments) are
  critical to selection of business models-how does Medicaid
  reimburse for care?
 In one FFS state, for psychiatric medication service 90862
      A university medical center clinic is reimbursed $12.50 via fee-for-
       service (FFS) Medicaid
      The same visit at a community mental health center would be
       reimbursed $39.92 FFS
      At a FQHC, the visit with a psychiatrist would be reimbursed at $80-
       88 (variable due to quarterly recalculated cost basis)
 In a FFS and managed care nearby state, for 90862
      A university medical center clinic is reimbursed $19.53 via fee-for-
       service (FFS) Medicaid
      The same visit at a community mental health center would be
       reimbursed $210.87 FFS
      At a FQHC, the visit with a psychiatrist would be reimbursed at
       $66.82-$155.64(variable due to quarterly recalculated cost basis)

Q I and Q III Business Models—
Who Owns the Staff?
 Placed staff: CMHC places staff on site
 Joint Venture: Common shared cost or grant
 Service contract: Primary care “purchases” BH
  services like lab or physical therapy [note that a
  barrier may be malpractice coverage]
 Primary care staff: BH clinicians are hired and
  supervised by primary care clinic
 In any circumstance, need to assess workload and
  productivity drivers
 In any circumstance, need to build relationship
  between primary care and specialty BH system

Q I and Q III Business Models—
Who Owns the Staff?
 It has been said that the service contract or
  “rental” model cannot be implemented in FQHCs
  that are covered by the Federal Tort Claims Act for
  malpractice—however, the “rental” agreement with
  a mental health center can be put in place as long
  as the mental health center provides the
  malpractice coverage (and includes that in costing
  the service)
 In some states, Medicaid will not reimburse for
  services provided by MFTs in FQHCs, even if the
  same state will pay for licensed MFTs in
  community mental health agencies
Q I and III Business Models
                   In PHC as Primary          In FQHC/RHC as BH           As CMHC BH Practitioner
                  Healthcare Provider             Practitioner               Providing Services
                                             (PIN 2004-05 option)              Located in PHC

Diagnosis               Physical             Psychiatric * or Physical           Psychiatric *
Authority                 PCP                 BH Practitioner or PCP            BH Practitioner

Billing under      PCP bundled services           MH benefit *                  MH benefit *
                  99201-5, 11-15 series     90804-29 series, individual   90804-29 series, individual
                    99078 educational           90853,57 group                90853,57 group
                     services- group            90846-49 family               90846-49 family
                99401-4, 11-12 prevention   99150-5 codes as come on      99150-5 codes as come on
                      interventions                   line                          line
                 0108 & 0109 for diabetes              Or,
                                                 Health benefit
                                                  96000 series
Documentation     In PHC medical chart         In RHC medical chart             CMHC records

Liability              PHC / BHP                    RHC/ BHP                     CMHC / BHP

Payments to               PHC                          RHC                          CMHC

                            MCPP Healthcare Consulting                      Based on Dyer, NCCBH    21
                                                                                Conference 03
The Money and the Business
 Washtenaw County represents the ultimate in public sector
  integration along with the Cherokee Health System in
 The variability of financing models for public sector BH
  requires every community partnership between a CHC and a
  mental health center to assess state and local financing and
  policy environment in order to determine what business
  model makes sense
 The National Council has developed a state level assessment
  tool for use in this process—it is available online at the
  NCCBH website Primary Care Resource Center

What questions do you have?


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