DEPARTMENT
OF HEALTH
For Public Comment and
Discussion:
A Work in Progress
This is a discussion paper meant
for comment and reaction.
Comments may be sent via e-mail
to Chris.Zukas-Lessard@Maine.gov
or in writing c/o, Chris Zukas-Lessard, DHHS, #11 State House Station,
Marquardt Building., 2nd Floor,
There will also be public
meetings held around the state to provide opportunity for reaction, questions
and discussion about the issues this paper raises. More about that soon for the
month of January.
TABLE OF CONTENTS
I. INTRODUCTION 4
II. PURPOSE OF THIS PAPER 4
III. DESCRIPTION OF CURRENT SYSTEM 5
IV. GUIDING PRINCIPALS IN THE DEVELOPMENT OF THE 5
NEW MANAGED CARE SYSTEM
For the Consumer and Family
For the Mental Health and Substance Abuse Delivery System
Desired System Results
V. PROCESS TO DATE 7
VI. IMMEDIATE NEXT STEPS, PROJECT TIMELINE AND 9
WORK PLAN
VII. PHASES OF THE BEHAVIORAL HEALTH SYSTEM’S 10
DEVELOPMENT
VIII.
POPULATIONS AND SERVICES TO BE INCLUDED IN THE 11 MANAGED CARE CONTRACT AS OF
Populations to be covered as of
Services to be covered as of
Additional Services Being Considered for Phase Two and Beyond
Financing Mechanisms
IX. STRUCTURE FOR A SINGLE BEHAVIORAL HEALTH 13
SERVICES DELIVERY SYSTEM
Functions of the State, MCO, Consumers and Families
Contracting with Providers
Pharmacy
X. MEMBER SERVICES AND CONSUMER/FAMILY 16
INVOLVEMENT
Education of Consumers, Families and Providers
Assistance with Enrollment/Registration
Complaints, Grievances and Appeals
XI. MCO AND PROVIDER ACCOUNTABILITY 18
XII. UTILIZATION REVIEW, UTILIZATION MANAGEMENT 18
AND COORDINATION OF SERVICES
Utilization Review, Utilization
Management (UM/
Coordination with Primary Care
XIII. QUALITY – PERFORMANCE MEASURES AND OUTCOMES 19
XIV. CONCLUSION 20
APPENDIX A 21
I.
INTRODUCTION
The
demand for coordinated services for consumers and families encouraged the Maine
Department of Health and Human Services to seek a better behavioral health care
delivery system, one which would foster creativity and increased responsiveness
to the needs of
The Department of Health and Human Services
is developing a behavioral health delivery system that is customer and family
directed, committed to recovery and resilience, able to integrate services
across multiple systems, is accessible in a timely manner and community-based.
The Department will focus on these goals and outcomes as it as it plans for the
behavioral health needs and designs and contracts for services in
II.
PURPOSE OF THIS PAPER
This
paper describes a process and a concept to improve the design and delivery of
publicly funded behavioral health care services in
This
paper also represents a commitment made in September of 2005 to behavioral
health stakeholders in
This
paper is a work in progress and represents the writings of the Behavioral
Health Work Group (BHWG). It is a group
is a group consisting of the following representatives from DHHS:
Brenda
Harvey, Deputy Commissioner for Integrated Services
Kim
Johnson, Director of the Office of Substance Abuse
Jim
Beougher, Director of the Office of Child and Family Services
Marya
Faust, Acting Director of the Office of Adult Mental Health
Cathy
Cobb, Acting Director of the Office of Elder Services
Joan
Smyrski, Director of Children’s Behavioral Health Services
Elsie
Freeman, Medical Director
Marie
Hodgdon, Director of Purchased Services
Chris
Zukas-Lessard, Medicaid Special Projects Manager
Jay
Yoe, Director of the Office of Quality Improvement
Kathy
Bubar, Director of Systems Integration, Region I
We
encourage interested persons to read and critique the concepts in this paper.
The paper reflects the initial thinking of the BHWG. Comments are welcome and
encouraged as we continue the process of creating a single behavioral health
service delivery system throughout
As
part of the development process, the staff reviewed prior efforts to improve
the mental health and substance abuse delivery systems. Since the early 1990’s a number of planning
groups have been meeting and have produced plans that have been responsive to
Federal requirements such as the Block Grant and State Requirements such as the
consent decree and children’s behavioral health system reform. A list of these groups and reports are
available in Appendix A
III.
DESCRIPTION OF CURRENT SYSTEM
The
existing behavioral health care delivery systems in
IV.
GUIDING PRINCIPALS IN THE DEVELOPMENT OF THE NEW MANAGED CARE
SYSTEM
Based
upon the review of the current system and the plans previously developed, DHHS
has developed the following principals to guide system change at all levels:
For the Consumer and Family
For the Mental Health and
Substance Abuse Delivery System
In
some cases, the individual goal of services provided is secondary to or
co-existing with the community goals of preventing incarceration or
re-incarceration or preventing behaviors that are inconsistent with community
safety. While recognizing and embracing the importance of these additional
goals, the managed care system will focus first on the best outcomes for the
individual and family served and believes that by doing so, the additional
system and community goals can also be met.
Desired System Results
Additionally,
the Department has developed interim objectives that will guide the development
of the managed care contract. The contracted MCO must be committed over time to
achieving the following system results:
V.
PROCESS TO DATE
Shortly
after the Legislature mandated that the Department move to behavioral health
managed care for all MaineCare funded mental health and substance abuse
services, the Behavioral Health Work Group was formed. The BHWG has guided and
will continue to guide the development of the new behavioral health system
until a contract with the MCO has been selected and is operational. At that point, the existing members of the
work group, with the addition of a number of advisors nominated by and chosen
from various advocacy and consumer groups will continue to guide the work on
this initiative.
The
following steps represent actions through
VI.
IMMEDIATE NEXT STEPS, PROJECT TIMELINE
AND WORK PLAN
The
Department is committed to having a single behavioral health service delivery
system in place, through a partnership with a MCO, by
The
Department is also developing a detailed Project Implementation Timeline and
Work Plan. The timeline and work plan will include timeframes for completion of
specific sections of the 1915(b) Waiver and contract/RFP document, assignment
of duties to responsible DHHS staff, and deliverables. These documents will be
available
This
is an aggressive timeline especially given the necessity to seek federal
approval of a 1915(b) Freedom of Choice waiver allowing the Department to move
to managed care. The Department is committed to continually evaluating progress
towards implementation and will adjust priorities and seek additional
assistance as necessary.
VII. PHASES OF THE BEHAVIORAL HEALTH SYSTEM’S DEVELOPMENT
It is
important to understand that
The
BHWG anticipates a planning and transition phase and at least three
implementation phases in the evolution of this new single behavioral health
delivery system.
Planning
and Transition
is already underway. Conceptualizing and planning for the new behavioral health
delivery system began as soon as the Legislature announced the behavioral
health initiative. Planning continues with the work of the BHWG and the
development of this concept paper. The most significant step of the transition
process includes the development of the request for proposals or a contract
that will define the design of the system and role of the MCO. The development of a Quality Strategy and
assuring that the outcomes and performance standards required by the Department
will be specified in the contract for all mental health and substance abuse
services.
Also
during this phase, a public involvement process for planning and implementation
will occur with consumers, families, providers and other stakeholders. Forums for all stakeholders will be held at
various locations around the state to solicit input and comments. Using the staff of the Department, it is
anticipated that a large number of forums can be held during January 2006 to
assure in so far as possible that all voices are heard. And finally during this process, decisions
for competition for the MCO contract and CMS waiver application will be made.
Phase
One will begin
During
this phase, the Department will work with the MCO to assure continuity of care
and services during the early months of the contract and a smooth transition to
the managed care service system. During this phase, transitional issues will
continue to be addressed, and goals for Phase Two will be developed. Initial
outcome measures and performance objectives will be in place and the MCO will
be judged on its ability to meet those criteria.
Also
during this phase, the Department and the MCO will work with local communities
to help those communities come together to assure the ongoing continuity of
care for all individuals in that community who receive services from the MCO. The Department is committed to the philosophy
that communities know their needs and can work with the MCO to assure that
those needs are met within the constraints of the available resources.
During
Phase Two, lasting up to two years (July 1, 2007 through June 30, 2009),
the staff from the MCO will work with representatives of the Departments of
Corrections and Education to establish more effective ways of identifying
multiple funding sources and funding mechanisms to support the outcomes of this
program. Performance objectives and deliverables will continue to be developed,
expanded and refined for each phase so that clear progress toward a
comprehensive behavioral health system is accomplished.
Additional
resources will be sought collectively by the State and MCO to address unmet
needs and identified priorities for service expansions. Phase Two may also see
the inclusion of additional funding streams and other resources, as well as
additional services not included in the initial RFP.
Phase
Three is
anticipated to begin no later than
VIII. POPULATIONS AND SERVICES
TO BE INCLUDED IN THE
MANAGED CARE ORGANIZATION CONTRACT
Populations to be covered as of
July 1, 2006
There
are more than 280,000
Services to be Covered as of
July 1, 2006
Relevant
behavioral health services under the following chapters of the MaineCare
Benefits Manual will be included in the initial MCO Contract:
Non-state plan services, like respite services to children and social clubs, will not be included at this time for any population.
Additional Services Being Considered for Phase Two and Beyond
The RFP may indicate that during Phase Two,
utilization of additional services and funding will be added to the MCO’s
responsibilities. While no decisions have yet been made, services and funding
being considered for inclusion in the MCO’s responsibilities to coordinate or
administer beginning in Phase Two include but are not limited to:
·
DHHS sexual assault services funding;
Any services provided through the
state should be coordinated with the services and funding that are the
responsibility of the MCO, whether the funding for those services are
contracted to the MCO to administer or retained to be administered by state
agencies. This means service definitions, service requirements, performance
expectations, referral and follow-up, participation in and utilization of a
single joint assessment and service planning process, early transition planning
and coordination of transition from one service setting to another, data
sharing, etc., must all be consistent or the same and/or shared throughout the
behavioral health service delivery system.
Financing Mechanisms
Funding
for the MCO will consist of a prepaid capitation rate for Medicaid services and
a 1/12 allocation for non-Medicaid eligible individuals.
IX. STRUCTURE FOR A SINGLE
BEHAVIORAL HEALTH SERVICE DELIVERY SYSTEM
Functions of the State, MCO,
Consumers and Families
The
initial plans regarding the functions of DHHS and the MCO are described briefly
here:
DHHS:
Develop and maintain the statewide behavioral health plan including planning to
meet state and federal requirements; grant writing and management; the
development of the State’s Quality Strategy including performance and outcome
indicator development and oversight; capitation and fee-for-service rate
setting development and maintenance of service definitions; assuring consumer/
family/citizen input, planning, oversight and implementation of training and
technical assistance; medical and clinical leadership; assuring the use of evidenced-based
practices; fraud and abuse monitoring;
and licensing and certification oversight.
MCO:
Financial management and oversight; delivery of training; contracting with and
monitoring providers; client outcomes; system outcomes; assuring consumer/family/citizen
input; enrollment of recipients service development; coding and configuration;
legal issues; establishing a single client identifier for data; utilization
management (UM); trending UM data; utilization criteria predictive
modeling/disease management guidelines; prior authorization (for certain
services); quality management and improvement; interpreter services; provider
services; member services (including formal grievances and appeals); claims
management/billing/payment; data
management; fraud and abuse; regulatory compliance; and implementation and
maintenance of provider credentialing.
Consumers
and Families: Involved in all aspects of contract development and oversight of
the MCO and its providers; identification of unique barriers and solutions, and
advising DHHS and the MCO about improved ways to seek and obtain consumer and
family involvement.
This
initial structure will be refined as stakeholders are brought into the
development process. Additionally, care coordination services and other issues
may affect decisions about structure.
In
preparing a Request for Proposals (RFP) and the contract for the MCO,
consideration will be given to those elements that support consumers and
families and incorporate long-term planning to address the gap between what is
needed and what is provided. At a minimum, the RFP/Contract will include the
following approaches: