Healthcare Reform and Changing Fiscal and Management Structures and What About Pennsylvania Dale Jarvis

2 Movie: Turning Oranges into Orange Juice

Key Fiscal and Management Structure Issues New $ and Consumers from Expansion & Parity Changes in Payor Mix 3 Provider-Level Changes So What About Pennsylvania

Coverage Expansion and Parity 31 to 36 million additional insured $16 - $25 billion new BH funding for this group To address needs of the 5.2 million indigent, uninsured in need of MH Parity and need to “bend curve” will result in increased demand for those already insured Page 4

Coverage Expansion and Parity Two layers of funding: Mild & Moderate and Serious & Severe (SMI/SED) Meeting ½ of the demand for specialty care will require 33,000 FTEs 5

Changes in Payor Mix Important changes will be unfolding in the payor landscape that will impact how states, health plans and providers operate 6

Provider Level Changes There are three changes unfolding that will impact the behavioral health service delivery system 7

Person-Centered Healthcare Homes Community Behavioral Healthcare Organizations need to engage with Medical/Healthcare Homes in one or more of three ways and there is not a “fourth door” for CBHOs 8

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Federally Qualified Behavioral Health Centers

2007 Revenues by payor for the 1,067 Federally Qualified Health Centers that have Section 330 Grants Note that revenue from the 330 Grants and Indigent Care programs are not available to CBHOs FQHCs also have higher Medicaid and Medicare revenue due to favorable Federal legislation 11

Federally Qualified Behavioral Health Centers A parallel structure for CBHOs, Federally Qualified Behavioral Healthcare Centers (FQBHC), based on the FQHC accountability and payment structures 10 benefits and the 8 responsibilities come with FQHC status 12

Federally Qualified Behavioral Health Centers The Community Behavioral Healthcare Organization(CBHO) system will need to adapt to this new model of service delivery and a high level of expectations from the general healthcare system Federally Qualified Behavioral Healthcare Centers (FQBHCs) will become the core of the new specialty system, supplemented by specialized, less comprehensive mental health and substance use provider organizations 13

Federally Qualified Behavioral Health Centers FQBHC status will create a single set of national standards that can serve as a blueprint for the types of services and infrastructure that need to be in place to better support the full healthcare needs of persons with serious mental health and substance use disorders In addition, the FQBHC designation creates a single, common platform of common assumptions, approaches, and expectations for FQHCs and FQBHCs to partner in providing person-centered healthcare homes The ability to achieve FQBHC designation and the accompanying financial benefits are necessary components for Community Behavioral Healthcare Organizations to be able to adapt to the changes that will occur in the general healthcare system 14

New Payment Structures & Reimbursement Models Funding methods for CBHOs are also going to need to change to address the imbalances in the current system, reverse existing incentives, and come into alignment with how the rest of healthcare will be funded 15 (Note: PPS = Prospective Payment System)

New Payment Structures & Reimbursement Models Funding is just starting to open up for embedding primary medical care into CBHOs, which is a critical component of meeting the needs of adults serious mental illness 16

So, What about Pennsylvania? 17

Page 18 Movie: Ice Fishing, Don’t Be Swallowed by Change

Overview of Pennsylvania’s Safety Net Population Of the 12.6 million Pennsylvania residents, 2.2 million fall into the Safety Net because they are indigent and uninsured or have Medicaid coverage (source: Kaiser Family Foundation State Health Facts) 19

How does PA MH Funding compare with other states? Pennsylvania is the most successful state in supporting funding for mental health services (note: this includes some SU $ but is missing some children’s $) 20

Analysis of MH Unserved in Pennsylvania In a FY2007 NCCBH Mental Health Gap Analysis, Pennsylvania: –Ranked #2 in Medicaid Gap (low # = low gap) –Ranked #50 in Indigent/Uninsured Gap (out of 51) (based on Kaiser Population data, national prevalence estimates, and Pennsylvania data submitted to SAMHSA on number served) Question: Where are the uninsured counts? In the County Allocations? 21

Pennsylvania Needs a Comprehensive Integration Plan PA stakeholders need to develop a Blueprints document that describes how we got her, where we need to go (clinical, structural, and financial designs) and a comprehensive demand, capacity, revenue and expense model 22

Pennsylvania Needs a Comprehensive Integration Plan 23

Stop Whining and Do Something This diagram lists eight steps in a process for transforming the public behavioral health system at the region, state and federal level.

Demand-Capacity, Revenue-Expense Planning

How Many People… Mental Health prevalence for a 3- County Region in rural Washington State.

How Much Service… The mental health system in Portland Oregon completed a clinical design, identified what services should be available to persons with SMI/SED as well as other Medicaid enrollees needing mental health treatment, and projected demand based on historical use, research, and projected utilization at each level. This slide projects use for non- SMI/SED persons.

How Much Service… This slide projects need for persons with SMI/ SED in Portland Oregon.

Pennsylvania Needs a Comprehensive Integration Plan Integration Policy Initiative: Collaboration of California’s public Mental Health and Primary Care community Grew out of acknowledgement that BH and PC have not adequately addressed whole health needs of persons with MH/SU conditions Addresses integration vision, values, principles, clinical models, implementation issues, and specific recommendations (delivery system, financing, and regulatory) 29

Federal Health Reform Timeline (based on Senate Finance Committee Bill) Eight key activities begin between 2010 and 2014 Requiring a great deal of implementation effort at the State and Federal levels 30

California’s 1115 Waiver Renewal Promote Organized Delivery Systems of Care –Enrollment in organized delivery systems for seniors and persons with disabilities and children and families in rural counties –Children with special health care needs –Dual-eligible beneficiaries –Adults with severe mental illness Strengthen and Expand the Health Care Safety Net Implement Value-Based Purchasing Strategies –Standardized reporting; risk sharing; pay-for-performance (P4P); healthy rewards and incentives for beneficiaries; and nonpayment for healthcare acquired conditions Enhance the Delivery System for the Uninsured to Prepare for National Reform 31

Pennsylvania Behavioral Health Key Issues What is Pennsylvania’s plan for addressing Medicaid expansion and development of Health Insurance Exchanges? What will be Pennsylvania’s stages of Health Plan evolution? How will Behavioral Health be managed inside the Exchanges – carve-in or carve-out? How ready are the state, plans, counties, and providers for wide and rapid deployment of person-centered healthcare homes? Is the concept of an Outpatient Behavioral Health System outdated and out of sync with the delivery system models of the near future? How many Pennsylvania providers are ready to become FQBHCs? How does Pennsylvania financially support embedding primary care clinics inside CBHOs/FQBHCs? What state regulations need to be re-written to align with needed clinical, structural and financing changes? Who will develop Pennsylvania’s comprehensive integration plan and when? How will attachment to the status quo systems and structures impact the ability of Pennsylvania to better align with national healthcare reform opportunities? Page 32