System Integration – and other miracles Idaho Behavioral Health Transformation Workgroup Panel March 25, 2010 Dave Wanser, Ph.D. Visiting Fellow LBJ School of Public Affairs Executive Director National Data Infrastructure Improvement Consortium

What are the issues and how do they connect? How are state agencies organized? How to structure collaboration? What needs to be in place beforehand? What options exist for managing care? How to hold the system accountable? What will braided funding actually look like? What needs to be in place first and what is the sequence for phasing in other desired changes?

What are the complicating factors? State budget uncertainty Incomplete grasp of financing of the various systems Shortage of qualified staff Insufficient community system State employee run versus private providers Lack of system alignment Plan for regional model What happened to the other 10 plans and planning efforts?

The Challenge:

Structural Integration of mental health and substance abuse systems Is the true cost of mental illness and substance use to state government known? How will subject matter expertise be maintained and strengthened? What new job skills are needed in an integrated system? Embrace a public health view of your role Deal realistically with the perceived threats

This is how substance abuse agencies perceive mental health in merged organizational structures Mental Health Substance abuse

Oversight structures for transformation Oversight can be very different than authority. Oversight can include everyone but authority can’t: –Oversight groups can’t manage contracts –Oversight groups can’t do data analysis –Oversight groups can’t keep up with the pace of change in transformed systems Oversight bodies frequently get bogged down by poor agenda development and management: lots of reports and little planning and recommending around the larger system issues Bigger isn’t always better Think through communication issues in advance Someone has to be fully engaged in steering the oversight structure

Logical steps for system design Develop a service package for each population Establish eligibility criteria for each service Determine distribution and capacity of these services across the state Identify the path for building additional service capacity Develop a financial model Ensure data collection capacity Draft contract Ensure economies of scale

Here’s what systems look like in the absence of those things

What are your expectations for a managed care system? Determine and enforce appropriate utilization of services Shape provider behavior Manage access and eligibility Pay providers Ensure quality Provide performance data

Ask yourself these questions: What keeps us from doing this ourselves? What’s our capacity to hold a contractor accountable and change their behavior? Will we let the entire system be managed or only part? Will we really let someone manage the system regardless of fallout? What could go wrong with the regionally administered provider network? How well do we understand risk based financing? By what means will additional community services emerge? Why should we be wary of a provider network disguised as a managed care entity

If this is your answer – rethink your plan

Key provisions of contracts with managed care entities Amount of capitation payment that needs to be spent on paid claims Prohibit sub-capitation for first 3 years and thereafter without state’s permission Successfully passing readiness review before allowing contract to commence Transition plan for moving providers to fee for service that haven’t been paid that way before Limit performance measures for initial years to focus on system development Consequences for not paying providers and supplying all required data State hospital utilization needs to be in the equation Require MCO to give at least a 90 day notice of intent to terminate

Characteristic of problematic managed care contracts

Determining roles for state and regional entities Everyone likes the concept of regional control Managing the system of care in a uniform way isn’t possible in this configuration What are the costs and benefits of various configurations What are the roles that can best be managed locally: –Planning –Stakeholder involvement –Ombuds services –Local government interface –Mediation What are the roles that the state should manage: –Contracting and contract management –Quality management –Data collection and analysis –Financial management –Providing direction to any managed care entity

Quality, outcomes and accountability 95% of current quality management activity is reactive – be part of the 5% Have you specifically defined how the system should work and how can you measure whether or not it is? What outcomes are most strategic and easily accessible? Quality, outcomes and accountability can be steered by the payor.

Managing quality and accountability requires getting your hands dirty

A few more challenges and risks Separating crisis and inpatient services, aka “guarantor of care” will create unintended consequences Beware of cost shifting By a conservative count there are no less than 5 current DHW MH and SA “systems”. How quickly can you align rules and data systems? –MH Adult state run –MH Children’s –Medicaid adult and child –Substance abuse adult –Substance abuse child

The alternative assignment: rearrange