Idaho BHTWG Panel March 25, 2010 Steve Holsenbeck, MD ValueOptions Colorado Partnerships

Panel Questions/Responses The underlying goal of all this work is to better and more effectively serve people. How do we assure our collective efforts are moving toward that end? ▫Develop consensus definitions: “better” and “effective”; ▫Agree on objective measurable indicators of each; ▫Measure, track, trend, and report comparatively; ▫Involve recipients of care in oversight at local level; ▫Reward improvement and recognize excellence; ▫Let natural consequences address poor performance.

Panel Questions/Responses What systems and structures must be in place in order to implement an outcome-based/managed care system? ▫Capacity to provide and collect essential data:  Eligibility, Services, Cost, Uniform Coding Manual, RVU based costing ▫Establish Planning Workgroups that become Implementation Workgroups that become Policy Workgroups. Add BHOs as they materialize.  Data Integrity and Standardization  Finance and Accounting  Quality and Performance Improvement

Panel Questions/Responses What experience can you share/advice can you provide regarding managing for quality assurance and accountability? ▫Nothing without QM. Measure everything! ▫Use a QM approach with financial as well as clinical data. Cost is a valid dimension of clinical activity. ▫Learn quickly from the dynamics between dollars, services, and outcomes. ▫Comparative data drives the race to the top. ▫Compare Regions, providers, etc. on rates per 1000, by eligibility category, by age, by diagnostic group, etc., to neutralize exceptionalism.

Panel Questions/Responses What specific recommendations do you have regarding the elements of our draft approach, and what specific steps would you take to implement those recommendations? ▫Harness the power of capitation!  Do NOT separate out crisis and inpatient. Capitate all services. ▫Create single entities responsible for entire behavioral health of geographically determined populations of at least 50k covered lives. Fewer regions than 7? ▫3/10/10 Draft approach to core services and service definitions is a great start! ▫1/19/10 Interim Report Next Steps is right on!

Panel Questions/Responses What other thoughts or perspectives would you share given your review of these materials? ▫Regional management entities must have:  Serious data collection, reporting and analytical capabilities;  Integrated phone, documentation, and data systems;  Financial strength and reserves sufficient to handle risk;  Management experienced in managing systems of care. ▫Successful implementation is critical to long term success. Allow enough time and $$ to get it right. ▫Allow enough administrative $$ to be effective, it’s harder than you think! 12-15% at first; gets more efficient with time.

Panel Questions/Responses What other thoughts or perspectives would you share given your review of these materials? ▫Move to RVU-based rational costing; ▫In capitation: reconcile encounters and costs with capitation payments from the outset >> If $$ are not accounted for, redistribute them. ▫Profit works (even for non-profits)! Consider reasonable caps.

Panel Questions/Responses What are your thoughts respective to when and how to integrate substance use and mental health from a structural perspective? ▫Make the same entity responsible for managing and paying for both. Then let change happen. ▫To spend time making a divided system better is a waste. Resistance only hardens with time.

Panel Questions/Responses What oversight structure would you recommend to sustain our transformation? ▫Matters most in year 1-2. ▫A benevolent dictator with wise advisors; ▫Half of transformation is getting it started. ▫The other half is staying out of the way and allowing it to happen, intervening ONLY to avoid death, disability, or disfigurement.

Panel Questions/Responses What do you see as the logical steps through system redesign? ▫De-fragment the system at every opportunity.

The Rules of Transformation People and dollars are falling through every seam in the system. Knit!

The Rules of Transformation You cannot both preserve and transform every player in the system of care. Everyone will not prosper. Some will and should wither away.

The Rules of Transformation Most of the good things will go unnoticed. ALL of the bad things will make the evening news.

The Rules of Transformation No Data = No Dollars

The Rules of Transformation There are a lot more $$ than you think! Taxpayer funding is not welfare for providers.

The Rules of Transformation In good times, self interest will trump altruism 70% of the time. In bad times, 95% of the time.

The Rules of Transformation Embracing change is hard. Making change is nearly impossible.