Welcome to the 2017 Town Hall June 6, 2017

Welcome & Introductions Trish Cortes, Executive Director of WCCMH Alan Bolter, Associate Director of MACMHB Washtenaw County Community Mental Health

Michigan Association of COMMUNITY MENTAL HEALTH Boards Washtenaw County CMH Update MACMHB ~ www.macmhb.org ~ 517-374-6848

FY18 Budget Process The budget has been completed in early-mid June over the past several years, but this year, who knows? MACMHB ~ www.macmhb.org ~ 517-374-6848

FY18 Budget Comparison – Integration / 298 FY18 Executive Recommendation Section 298 – The department shall continue working with stakeholders to improve the coordination of publicly funded physical health and behavioral health services in Michigan. All efforts made towards improving the coordination of supports and services for persons having or at risk of having intellectual disabilities, developmental disabilities, substance use disorders, mental health and physical health needs shall be built upon the published core values agreed upon by the Section 298 Stakeholder Workgroup. These values include, but are not limited to, person centered planning with the expectation of high quality and consistent care provided statewide. FY18 Senate Section 234: The department shall advance pilots and demonstration models that integrate the Medicaid behavioral and physical health benefit. In fulfilling the directive described in this section, the department shall periodically consult with stakeholder groups, the medical care advisory committee, and the house and senate appropriations subcommittees on the department budget. For the duration of the integration pilot or demonstration model, the managing Medicaid health plan shall capture all behavioral health efficiency savings and reinvest those savings back into services for the Medicaid behavioral health population covered by the pilot or demonstration model. Upon completion of any pilots or demonstration models advanced under this section the results of the pilot or demonstration model must be evaluated by a neutral, independent, third party. The managing Medicaid health plan must submit a report to the senate and house appropriations subcommittee on the department budget, the senate and house fiscal agencies, the senate and house policy offices, and the state budget office by April 1 on any efficiencies and savings resulting from the pilot or demonstration model. The demonstration models are based on a goal to achieve total Medicaid benefit and financial integration by September 30, 2020 that will rely on a single contracting model between this state and licensed health plans, regulated by both the department of insurance and financial services to assure financial viability and the department to assure overall programmatic performance.

FY18 Budget Comparison – Integration / 298 FY18 Senate Section 298: The department shall continue working with stakeholders to improve the coordination of publicly funded physical health and behavioral health services in this state.   All efforts made towards improving the coordination of supports and services for persons having or at risk of having intellectual disabilities, developmental disabilities, substance use disorder, or mental health, and physical health needs shall be built upon the published core values agreed upon by the Section 298 Stakeholder Workgroup.  These values include, but are not limited to; person-centered planning with the expectation of high quality and consistent care provided statewide. It is the intent of the legislature that the department shall consider outcomes of pilots implemented under this section and the integration pilots recommended under section 234 when assessing and making recommendations regarding the most effective financing and service delivery models for the provision of Medicaid behavioral health services. Upon completion of any pilots or demonstration models advanced under this section the results of the pilot or demonstration model must be evaluated by a neutral, independent, third party. MACMHB ~ www.macmhb.org ~ 517-374-6848

FY18 Budget Comparison – Integration / 298 FY18 House Section 298: For the items described in subsections (2) and (3), the department shall demonstrate both the successes and weaknesses of altering the behavioral health services delivery system. In evaluating the successes and weaknesses, the department shall consider all of the following, including, but not limited to, improvement of the coordination between behavioral health and physical health, improvement of services available to individuals with mental illness, intellectual or developmental disabilities, or substance use disorders, benefits associated with full access to community-based services and supports, customer health status, customer satisfaction, provider network stability, and financial efficiencies. Any and all realized benefits and cost savings of altering the behavioral health system shall be reinvested in services and supports for individuals having or at risk of having mental illness, intellectual or developmental disabilities, or substance use disorders. The evaluation described in this subsection shall be performed by researchers from one of the state's research universities.   (2) The department shall work with a willing CMHSP in Kent County and willing Medicaid health plans in the county to pilot a full physical and behavioral health integrated service model consistent with the stated core values of the workgroup established in section 298 of article X of 2016 PA 268. (3) The department shall implement a public statewide behavioral health managed care organization consistent with the core values stated by the workgroup described in subsection (2). The organization shall operate in conjunction with an appointed state commission that shall consist of appropriately identified and diverse members. (4) In addition to the pilot described in subsection (2), the department shall implement up to 3 pilots to achieve a total Medicaid behavioral health and physical health benefit and financial integration demonstration model. These demonstration models shall use single contracts between the state and each licensed Medicaid health plan that is currently contracted to provide Medicaid services in the geographic area of the pilot. The department shall ensure the pilots described in this subsection are implemented in a manner, including, but not limited to: That allows the CMHSP in the geographic area of the pilot to be a provider of behavioral health supports and services. That any changes made to a Medicaid waiver or Medicaid state plan to implement the pilots described in this subsection must only be in effect for the duration of the pilots described in this subsection. That is consistent with the stated core values as identified in the final report of the workgroup established in section 298 of article X of 2016 PA 268. That provides updates to the Medical Care Advisory Council, Behavioral Health Advisory Council, and Developmental Disabilities Council." and renumbering subsections accordingly. (5) By March 15 of the current fiscal year, the department shall report to the house and senate appropriations subcommittees on the department budget, the house and senate fiscal agencies, the house and senate policy offices, and the state budget office on progress, a time frame for implementation, and any identified barriers to implementation of the items described in subsections (2) and (3). In addition, the report shall also include information on policy changes and any other efforts made to improve the coordination of supports and services for individuals having or at risk of having mental illness, intellectual or developmental disabilities, or substance use disorders, or physical health needs.

FY18 Budget Comparison – Integration / 298 What is in the Senate language (section 234 & 298)? Pilots that integrate physical and behavioral health care (very little details about pilots) Health plan pilots shall reinvest savings/efficiencies back into behavioral health services. Goal of complete system integration by 9/30/2020, with the state contracting with MHPs. Department shall use the pilots/demonstration projects for basis of final recommendations. Upon completion of any pilots an evaluation by a neutral third party shall review the results. MACMHB ~ www.macmhb.org ~ 517-374-6848

FY18 Budget Comparison – Integration / 298 What is in the House language (298)? Evaluation of successes and weaknesses, including: improvement of the coordination between behavioral health and physical health, improvement of services available, benefits associated with full access to community-based services and supports, customer health status, customer satisfaction, provider network stability, and financial efficiencies. The evaluation shall be performed by a state research university. On the ground pilot in Kent Co that shows clinical and service delivery integration where the consumer/patient is served. Department shall implement one statewide public behavioral health managed care organization. Allow for up to 3 health plan led pilots Allows CMHSP to be a provider (doesn’t say sole or main provider) Any waiver change is only in effect for the during of the pilot. Consistent with core values identified in 298 final report. Provides updates to key groups – Medical Care Advisory Council, Behavioral Health Advisory Council, and DD council. Requires a report by March 15 to update progress, time frame for implementation and any barriers. MACMHB ~ www.macmhb.org ~ 517-374-6848

Section 298 Advocacy Effort Concerns Regarding Health Plan Run Pilot 1. Health Plans do not have a good track record managing behavioral health services Medicaid Health Plans for 20 years have administered a benefit for persons with “mild-to-moderate” mental health conditions, and have done a very poor job with it. According to MDHHS, the average number of mental health visits authorized for qualifying MHP enrollees in 2014 was 4. In 2015, only 10% of all contacts for Medicaid recipients seeking behavioral health services were with a behavioral health professional. The Medicaid-Medicare multi-year demonstration project (MI Health Link) in four state regions has been a failure, with the vast majority of eligible individuals choosing to dis-enroll from the project. In spite of the fact that program automatically assigns these persons to a private health plan for their physical healthcare, when given a choice to stop these health plans from managing their care, 65% of these dual enrollees choose to leave these health plans. MACMHB ~ www.macmhb.org ~ 517-374-6848

Section 298 Advocacy Effort 2. Less Money for Services Medicaid health plans have higher overhead (on average 15% overhead compared to 6% for PIHP system). Medicaid health plans are profit-driven – 7 of 11 are for-profit insurance companies. Most health plans claim their profit margin is around 3-4% 3-4% profit margin on $2.6 billion = $78 - $104 million NOT going into services. After Michigan expanded Medicaid coverage the state’s Medicaid health plans saw their profit margins soar showing an income of $298 million in 2015 and a 3.9 percent margin, compared with income of $163.1 million in 2014 prior to the implementation of Medicaid expansion according to July 27, 2016 Crain’s Detroit Business report. 3. What are we trying to accomplish? " it depends on what the meaning of is, is"? Bill Clinton , August 17, 1998 What does integration mean / what do we want to measure? Apples to oranges comparison Physical health care and behavioral health care outcomes do not align MACMHB ~ www.macmhb.org ~ 517-374-6848

Section 298 Advocacy Effort What we would like to see in the final version Overarching Suggestions   REMOVE – Section 234 of the Senate DHHS budget, specifically language referring to total Medicaid benefit and financial integration by 9/30/20, which would transfer all Medicaid resources to Medicaid Health plans.  This language predetermines the outcome of the process without any input from pilots or other measurables and completely ignores the 298 workgroup process and the will of the people. INCLUDE – Ensure that the policy and management role for Michigan’s Medicaid behavioral health, intellectual/developmental disability, and substance use disorder services and supports system remains public. If we are going to have pilots – Items to be included in 298 integration pilot language Before Pilots Begin Clearly define what we are hoping to accomplish (measurables/outcomes, etc). Complete a feasibility study – items to be included, but not limited to: state statute change, federal waiver approval or state plan amendment, fiscal impact, timeframe for implementation.

Section 298 Advocacy Effort What we would like to see in the final version, cont. Components to be included in pilot projects   The pilots must meet the current standards related to person centered planning, recipient rights, and consumer representation on governing boards, as outlined in the Michigan Mental Health Code and MDHHS rules and regulations; and reporting as outlined in Section 904 of the MDHHS Budget bill. Medicaid enrollees should be able to opt-in to the pilot – to ensure the current system, in the pilot communities, is not prematurely eliminated while also ensuring consumer choice. Health plans should not be allowed to capture a profit if they manage a pilot or demonstration project. The pilots should have a rigorous evaluation component that examines the performance of the pilots along key dimensions.  The evaluation of these pilots should be carried out by researchers from within one of Michigan’s universities or a neutral third party. MACMHB ~ www.macmhb.org ~ 517-374-6848

Direct Care Wage Increase FY18 Executive Budget The governor’s budget includes new funding to support direct care workers who provide critical hands-on supports and services (e.g., personal care services, mobility support) to residents served through Michigan’s community mental health system. An investment of $45 million ($14.2 million general fund) will increase payments to Pre-Paid Inpatient Health Plans responsible for managed care within the mental health system. Funding will support an estimated $0.50 per hour increase in wages for this workforce, with the goal of reducing turnover among care providers and improving the quality and stability of services and supports. FY18 Senate Budget Delays .50 cent direct care worker wage increase by 6 months – start date would be April 1, 2018. Reduces spending by $22.5 million (gross) / $7.08 (GF) FY18 House Budget Decreases Medicaid mental health services line by nearly $20 million less than the Governor’s budget. (It was reduced based on the change to the direct care wage pass-through going from .50 cents to .25 cents) MACMHB ~ www.macmhb.org ~ 517-374-6848

Federal Healthcare Reform 216 Votes needed in House to pass MACMHB ~ www.macmhb.org ~ 517-374-6848

Federal Healthcare Reform Congressional Republicans: American Health Care Act (as passed on 5/4/17) PRIVATE HEALTH INSURANCE IMPACT Eliminate individual and employer mandates Offer tax credit vs. subsidies Children can stay on parents insurance until 26 Allows states to waive the essential health benefit rules and set up their own standards. Allows states to waive the pre-existing medical conditions rule restricting price differences based on health. Insurers would be allowed to charge higher prices to sick customers who had experienced a lapse in coverage of more than 63 days, as long as the state also set up a program to help high-risk patients obtain insurance. Adds $8 billion over five years to help people with pre-existing medical conditions (high risk-pool) Would allow insurers to charge older customers five times as much as younger ones. But states could waive that rule and establish an even higher ratio. MACMHB ~ www.macmhb.org ~ 517-374-6848

Federal Healthcare Reform Congressional Republicans: American Health Care Act MEDICAID EXPANSION Maintains the ACA’s higher federal financing for Healthy Michigan Plan through the end of 2019. After that, states can only continue to receive enhanced federal payments for beneficiaries already covered (and continuously covered) by HMP. Newly enrolled beneficiaries and those who churn on and off the program (which represents almost half of the current 650,000), the federal government would provide a lower level of financing – standard Medicaid match rate.  Allows states to impose work requirements for some Medicaid beneficiaries. MACMHB ~ www.macmhb.org ~ 517-374-6848

Federal Healthcare Reform Congressional Republicans: American Health Care Act MEDICAID Overhauls the broader Medicaid program to end its open-ended federal financing. Instead, each state would receive a limited per capita cap amount based on its enrollment and costs. That federal payment would be increased according to a government measure of medical inflation.   It proposes capping federal funding per enrollee, based on how much each state was spending in 2016. States also have the option to receive a lump-sum block grant. MACMHB ~ www.macmhb.org ~ 517-374-6848

Federal Healthcare Reform Table 1: Current Medicaid Program Financing Compared to Per Capita Cap Financing   Current Program Per Capita Cap Entitlement to Coverage Federal core coverage requirements for children to 133% FPL, pregnant women to 133% FPL, parents to old welfare standards, and elderly and people with disabilities tied to Supplemental Security Income or 75% FPL ACA coverage to nearly all adults up to 138% FPL State options to provide coverage above core requirements Guaranteed coverage for all eligible, no waiting list or caps Federal core requirements could be changed from current law; instead of core requirements, federal government could impose lower and upper limits for eligibility ACA could be repealed States could have options on eligibility but may not be able to access federal matching dollars for coverage beyond upper limits Assumes that once eligibility limits are established, no waiting lists or caps State / Federal Funding Federal funds based on FMAP formula in the law (floor of 50% to a high of 74% in 2016).  Enhanced matching for newly eligible under the ACA and for some specific services Guaranteed to match state spending with no cap Adjusts to changes in program needs, costs and enrollment Federal share of payments would be capped with pre-set amount per enrollee (total or by population group) Unclear about requirements for state matching dollars States may incur costs beyond those covered by federal per enrollee payments Adjusts for changes in enrollment Funding typically indexed to pre-set growth amount that does not account for changing program needs or costs

Michigan Association of Community Contact Information Michigan Association of Community Mental Health Boards Alan Bolter Associate Director abolter@macmhb.org (517) 374-6848 MACMHB ~ www.macmhb.org ~ 517-374-6848

Questions? Contact Customer Service at: 734.54.6807 or customer_service@ewashtenaw.org Washtenaw County Community Mental Health