DSHS, NTBHA, Value Options, A Collaborative Review and Discussion of NorthSTAR System Performance and Trending Data March 25, 2011 DSHS, NTBHA, Value Options, Select NorthSTAR Providers and Stakeholders

Goals of Presentation To update the stakeholder community on data that DSHS is tracking To discuss other ways to look at the data and analyze it at a more granular level Evaluate/discuss opportunities for quality improvement and further analysis 03/25/2011

What is Different or New from the Last Presentation in September 2010? Tables/graphs that were presented from last report in September 2010 have been updated: increases in enrollees served and funding from 2000 to 2011 (page 5) acute rates by RDM and non RDM in percentages (page 17) community service follow-up separated by ER and 23 hour observation (page 26) length of SUD treatment separated for adults and kids (pages 31 and 32) New measures have been added that drill further down into the data: the top 200 utilizers in 2010 (page 8) readmissions to ONLY acute SUD and ONLY acute MH services (page 20) 03/25/2011

Performance Measures: What is being measured and what data are being used? Financial Data-Medical Loss Ratio, Cost Per Person Served (Medicaid vs. Non Medicaid funding per person), Acute Costs Relative to Overall Costs Service Penetration: Numbers served Clinical measures (TRAG), follow-up post discharge from acute services, length of treatment episode (SUD services), 60 day follow-up post discharge from SUD treatment services Acuity Rates relative to persons served in non-acute services, overall and by SPN Complaints and Appeals Utilization management Enrollee satisfaction (based on last survey in April 2010) Provider Network Activity Data Sources: NorthSTAR enrollment system, DSHS invoices, paid claims data (services and medications), ValueOptions financial and utilization management reports, WebCARE, BHIPS, state hospital data system, complaints and appeals data collection system, satisfaction surveys Caveats to the Data: Generally, data represented in graphs or tables are incomplete in the last 1-2 months or latest fiscal quarter. 03/25/2011

Financial Performance 12/1/2018 Financial Performance Note: This is based on cash payment from DSHS payment invoices and numbers of enrollees served, which is based on paid claims. Recent months are inflated due to claims lag. FY00 FY10 Change FY00 to FY10 FY11 to date Number of Enrollees Served (MH and SUD) 30,742 67,592 119.87% 47,649 Funding $78,787,144 $117,876,393 49.61% $70,879,951 Annual Cash Funding per Enrollee Served $2,563 $1,744 -31.95% $1488 Note: There has been a considerable loss of bed days in State Hospitals since 1999. 03/25/2011

Medical Loss Ratio 03/25/2011

An Illustration of Funding Disparities by Medicaid and Non Medicaid FY10 Monthly Average FY11 (thru Jan 11) Medicaid Funding $ 4,726,459.55 $ 5,272,255.54 Non Medicaid Funding $ 4,734,524.98 $ 4,964,976.08   Medicaid Served 11,419 12,205 Non Medicaid Served 13,460 13,798 Funding Per Medicaid Enrollee Served $ 413.90 $ 431.98 Non Medicaid Enrollee Served $ 351.74 $ 359.84 Non Medicaid Per Person Percentage of Medicaid Per Person 85% 83% Note: Unlike non Medicaid enrollees, Medicaid recipients enrolled in NorthSTAR receive their medications through Medicaid, not NorthSTAR. The Medicaid funding per Medicaid enrollee served represented above does not include funding associated with this pharmacy benefit. Therefore, the actual Medicaid funding per Medicaid NorthSTAR enrollee is significantly higher than represented above. For instance, the non Medicaid medication costs relative to the non Medicaid funding is about 16%. Factoring in this percentage to the Medicaid funding per Medicaid enrollee served would further increase the disparity. 03/25/2011

Top 200 Utilizers in FY2010 Service Enrollees Encounters2 Units3 Amount State Hospital 200 390 35,431 $11,703,217 Community Inpatient 118 119 1,148 746,265 Medication1 129 2,289 63,093 577,860 ACT 73 75 378 329,575 Observation Room 105 105 348 269,352 Psychosocial Rehabilitation 69 69 1,898 53,372 Emergency Room Services 74 171 406 45,061 Medication Services 109 170 624 21,470 Supported Housing 26 26 925 12,950 Transportation 39 39 350 12,250 Skills Training and Rehab 26 26 448 9,450 Community Inpatient Services 86 102 164 9,084 Other 70 70 427 8,967 Crisis Stabilization 3 3 21 6,300 SUD Residential 3 4 47 6,210 Clinical Assessment 32 32 35 4,929 Case Management 24 24 142 4,262 Outpatient Counseling 10 16 63 3,207 Supported Employment 4 4 51 1,785 Laboratory 24 27 116 1,521 Jail Diversion 1 1 2 600 MH Intensive Outpatient 1 1 3 600 CD Non Residential 2 2 24 405 Medication Training 3 3 32 331 Crisis Intervention Services 3 3 9 268 TOTAL $13,829,246 Note: Each enrollee may have multiple services. Data exclude those enrollees with 355 or more days in the state hospital during FY10. This includes 75 enrollees with 89 hospital stays and 27,332 bed days at a cost of $6,969,737. 1Medication includes both Medicaid and non Medicaid drugs. Medicaid had 1,582 claims with 44,728 days of supply at a cost of $505,839. Non Medicaid had 707 claims with 18,365 days of supply at a cost of $72,021 (including administrative fees). 2Encounters for State Hospital data are number of hospital stays. Encounters for Medication data are number of claims. 3Units for State Hospital data are number of bed days. Units for Medication data are days of supply. 03/25/2011

Number Of Enrollees Served, Overall and By Service Category Note: Data based on MH specific service and non MH specific service coupled with MH primary diagnosis on paid claims, OR Substance Use Disorder (SUD) specific service and non SUD specific service coupled with SUD primary diagnosis on paid claims. 03/25/2011

Mental Health and Substance Use Disorder Services - 2 Views Note: Substance Use Disorder services are those in SUD Residential or SUD Non Residential or those in ER, 23 hour observation, community inpatient or community inpatient services with a diagnosis of Alcohol Related Disorders or Drug Related Disorders. These data are confined to services which occur within 90 days of one another. The focus for DSHS staff is to work with NTBHA and VO and also monitor this by visiting providers and conducting chart reviews. We want to determine if sufficient collaboration between MH and SUD providers is occurring with clients being linked to services when clinically indicated. This measure continues to be further analyzed. 03/25/2011

Mental Health and Substance Use Disorder Services – cont. Note: Substance Use Disorder services are those in SUD Residential or SUD Non Residential. These data are confined to services which occur within 90 days after a TRAG assessment. This measure continues to be further analyzed. 03/25/2011

Number Of Enrollees Who Received a Prescription Paid for by ValueOptions 03/25/2011

Acute Care by LOCA Adult Youth 03/25/2011 Note: Includes enrollees served in ER, 23 Hour Observation and Community Inpatient as a percentage of enrollees with a LOCA within the month. LOCA 2.1 for youth not included since there are so few enrollees. When the data are analyzed for acute utilization after a LOCA within the month, the percentages decline to about 78% of the adult percentages and about 68% of the youth percentages. 03/25/2011

Adult Acute Rates by SPN Note: Table shows enrollees with a LOCA and an acute encounter within the same quarter as a percentage of all enrollees with a LOCA within the quarter. Does not distinguish if LOCA assignment was before or after acute encounter. When the data are analyzed for acute utilization after a LOCA within the month, the percentages decline to about 78% of the adult percentages. 03/25/2011

Youth Acute Rates by SPN Note: Table shows enrollees with a LOCA and an acute encounter within the same quarter as a percentage of all enrollees with a LOCA. Does not distinguish if LOCA assignment was before or after encounter. When the data are analyzed for acute utilization after a LOCA within the month, the percentages decline to about 68% of the youth percentages. 03/25/2011

Claims Dollars Expended by ValueOptions on Acute and Non Acute Service Groups (Does not include State Hospitalizations.) 03/25/2011

Acute Rates by RDM and non-RDM Cohort Note: Acute services include ER, 23 hour observation and community inpatient/services. 03/25/2011

ER or 23 Hour Observation as a First Encounter (paid on a claim) for an Enrollee Note: Does not include mobile crisis as a first encounter, because mobile crisis services are not paid via a claim. 03/25/2011

Readmissions to Psychiatric Hospital Note: Includes community and state hospital encounter data. Data based on discharge date. A re-admission is based on a least a one day gap between a discharge and an admission. 03/25/2011

Readmissions to ONLY Acute SUD and MH Services Note: SUD services are those with a primary diagnosis of alcohol or drug related disorders. MH services are those with a primary diagnosis of schizophrenia, affective disorders or other psychoses. Acute services are ER, 23 hour observation and community inpatient/services. Readmissions include only acute services, without intervening routine services, within a year after a break of at least 15 days. 03/25/2011

Enrollee Presentations to Dallas Metrocare’s After Hours Clinic NOTE:  Primary reason for presentation to this service is due to a person’s inability to get in to see their psychiatrist for a refill, usually after missed appointment. The second most common reason is people brought in by mobile crisis or from Bridge (Dallas Homeless Assistance Center) to get back on medications. 03/25/2011

Adapt Community Solutions Telephone Hotline Data (incoming calls) Note: Not Reported, Out-of-State and Texas Residence Unknown data are included in Non NorthSTAR counties category. Data include crisis and informational calls. 03/25/2011

Adapt Community Solutions Mobile Crisis Data (face to face encounters) Note: Not Reported, Out-of-State and Texas Residence Unknown data are included in Non NorthSTAR counties category. 03/25/2011

Follow-Up with Non-Acute Services After Discharge From Psychiatric Hospital Community Hospital Discharges State Hospital Discharges Note: Data based on discharge date. Follow-Up Services include community based services covered by NorthSTAR excluding ER, 23 hour observation, inpatient hospital, intensive crisis residential or other crisis services. 03/25/2011

Enrollees who see a Prescriber after Discharge from Psychiatric Inpatient 03/25/2011

Enrollees Who Receive Community Services after ER or 23 Hour Observation Note: Community services include community based services covered by NorthSTAR excluding ER, 23 hour observation, inpatient hospital, intensive crisis residential or other crisis services. Green Oaks 8 hour services are reported under the ER columns. 03/25/2011

Select TRAG Dimension Trends Adults-Acceptable or Improving Note: Functioning: Acceptable – 1 on latest and first; Improving - latest < first. Employment: Acceptable – 1 on latest and first; Improving – latest < first. Criminal Justice: Improving - latest < first and first 2+. Housing: Acceptable - 1on latest and first; Improving - latest < first. Substance Use: Acceptable - 2 on latest and first; Improving - latest < first and first > 1. 03/25/2011

Select TRAG Dimension Trends Youth-Acceptable or Improving Note: Functioning: Acceptable - -9 < OFS Difference < 9 and latest OFS >= 54; Improving - OFS Difference >= 9. Criminal Justice: Improving - latest < first and first > 1. Substance Use: Acceptable – 2 on latest and first; Improving - latest < first and first > 1. School Attendance: Improving – latest < first and first > 2. 03/25/2011

Select TRAG Dimension Trends Adults-No Change or Worsening Note: Functioning: No Change – latest = first and latest > 1; Worsening – latest > first; Employment: No Change – latest = first and latest > 1; Worsening – latest > first; Criminal Justice: No Change – latest = first and first > 1; Worsening – latest > first and first > 1; Housing: No Change – latest = first and latest > 1; Worsening – latest > first; Substance Abuse: No Change – latest = first and first > 2; Worsening – latest > first and first > 1. 03/25/2011

Select TRAG Dimension Trends Youth- No Change or Worsening Note: Functioning: No Change - -9 < OFS Difference < 9 and latest OFS < 54; Worsening – OFS Difference <= 9. Criminal Justice: No Change – latest = first and first > 1; Worsening – latest > first and first > 1; Substance Abuse – No Change – latest = first and latest > 2; Worsening – latest > first and first > 1; School Attendance: No Change – latest = first and first > 2; Worsening – latest > first and first > 2. 03/25/2011

Substance Use Disorder-Length of Treatment Episode Adult Note: Data for previous 90 days may not be complete as persons may be transitioning between levels of care and not captured in the data. Data exclude Methadone Services. 03/25/2011

Substance Use Disorder-Length of Treatment Episode Youth Note: Data for previous 90 days may not be complete as persons may be transitioning between levels of care and not captured in the data. Data exclude Methadone Services. 03/25/2011

Readmissions to Substance Use Disorder Treatment within a Year Note: Measures percentage of readmissions to residential/nonresidential SUD services within a year after a break in treatment of at least 15 days. For example, 3.0% of residential/nonresidential SUD services in Sept-10 were readmissions to SUD services within the past year. Enrollees could get services other than residential/nonresidential SUD services during this time period. This includes multiple services and multiple readmissions by an individual enrollee. 03/25/2011

Substance Use Disorder Follow-Up After Discharge from SUD Treatment Adult Youth Note: Data are based on the discharging provider’s telephonic interview data of enrollees 60 days after discharge. This measure is being reevaluated in light of the new Clinical Management for Behavioral Health Services (CMBHS) system. 03/25/2011

Enrollee and Provider Complaints Note: On a monthly basis, most provider complaints are against ValueOptions regarding claims payment and utilization management issues. Most of these come from a limited number of providers. Most enrollee complaints are against NorthSTAR providers regarding quality and access to care issues. See specific Member Satisfaction Survey results on the following pages. 03/25/2011

Enrollee Satisfaction/Dissatisfaction with Services-Conducted in April 2010 Note: Survey to be re-administered in April 2011. 03/25/2011

Utilization Management-Adverse Determinations and Overturn Rate Upon Appeal Note: Data incomplete due to claims lag. Revisions will be made as new data become available. 03/25/2011

Medical Necessity Adverse Determinations, by Specific Service Category Note: Out of a total of 1017 total Adverse Determinations from April 2010 to March 2011, 71% (724 total) were from three levels of service: 23 hour observation, MH inpatient and SUD residential. 03/25/2011

Provider Network Activity-Providers that have served at least one NorthSTAR enrollee (based on a paid claim) Note: Large providers with multiple sites are only counted once. OTHER VIEWS: FY10 Average Monthly Number of Providers who served <= 25 enrollees is 151 providers; 26 to 50 enrollees is 17 providers; 51 to 100 enrollees is 9 providers; 101 to 250 enrollees is 7 providers; and >= 251 enrollees is 19 providers. 03/25/2011

Summary, Questions for Consideration and Possible Next Steps Utilization in mental health services continues to climb. Utilization in SUD services is relatively flat compared to previous periods and to mental health services. Average duration of SUD treatment episode seems somewhat brief. Possible comparison of this top 200 ulilizers list to the Dallas BHLT’s list. Follow-up rates after discharge from acute services will need to be examined further. The 8 hour Green Oaks service needs to be removed from the ER service counts. Acute rates for some SPNs have increased from FY10 Q1 to FY11 Q1. The increases should be monitored and reviewed for trends. Contact with the SPNs and VO regarding the causes should be initiated. 03/25/2011

More information may be found on the NorthSTAR web page: Questions?? More information may be found on the NorthSTAR web page: http://www.dshs.state.tx.us/mhsa/northstar/northstar.shtm Specific questions may be addressed to the appropriate staff contact: http://www.dshs.state.tx.us/mhsa/northstar/staff.shtm 03/25/2011