1. A Primer on Healthcare Reform: Key Concepts and Getting Ready – Next Steps
Presented to the System Leadership Team
July 9, 2010
Robin Kay, Ph.D.
Chief Deputy Director

2. Healthcare Reform: Data that Sets the Stage
Less than 5% of Medicaid beneficiaries account for more than 50% of overall Medicaid costs (not just mental health)
45% of beneficiaries have 3 or more chronic conditions
49% of beneficiaries with disabilities have a psychiatric illness
(Source: Center for Healthcare Strategies October 2009)
July 9, 2010
County of Los Angeles – Department of Mental Health
A Primer on Healthcare Reform

3. Healthcare Reform: Four Key Components
Insurance Reform
Coverage Expansion
Delivery System Redesign
Payment Reform
July 9, 2010
County of Los Angeles – Department of Mental Health
A Primer on Healthcare Reform

4. Healthcare Reform: Four Key Components
Delivery System Redesign: Changes in Service Delivery Models
Concept of Medical Home/Behavioral Healthcare Home
4-quadrant model from The National Council for Community Behavioral Healthcare
July 9, 2010
County of Los Angeles – Department of Mental Health
A Primer on Healthcare Reform

5. Healthcare Reform: Four Key Components
Quadrant II
Mental Health: High Risk
Physical Health: Low Risk
Integration of physical health practitioners in mental health setting.
Wellness activities.
Access to more comprehensive medical settings.
Provision of array of specialty mental health services
Community Behavioral Healthcare Home
Quadrant IV
Mental Health: High risk
Physical Health: High risk
Quadrant I
Mental Health: Low Risk
Physical Health: Low risk
Mental Health consultant/staff integrated into physical healthcare teams and settings.
Screening for mental health issues with general mental health interventions
Healthcare Home
Quadrant III
Physical Health: High Risk
Mental Health consultant/staff is integrated into physical healthcare settings.
July 9, 2010
County of Los Angeles – Department of Mental Health
A Primer on Healthcare Reform

6. Healthcare Reform: Four Key Components
Delivery System Redesign: Changes in Service Delivery Models (Con’t)
Possible Structural Alternatives
Fully Integrated Programs
One provider with ability to address all 4 quadrants through several team approaches
Formal Partnerships between Primary Care and Behavioral Health Providers
Two organizations with operational agreement
July 9, 2010
County of Los Angeles – Department of Mental Health
A Primer on Healthcare Reform

7. Healthcare Reform: Four Key Components
Possible Structural Alternatives (Con’t)
Behavioral Health Providers with Established Links to Many Primary Care Programs
Current arrangement in LAC-DMH
National Council Recommended Mandatory Elements:
Regular screening at time of psychiatric visits
Identify primary care provider for all clients
Explicit methods for communication and care coordination with primary care providers
Provide education and linkage to self-management assistance and support groups
July 9, 2010
County of Los Angeles – Department of Mental Health
A Primer on Healthcare Reform

8. Healthcare Reform: Getting Ready
Next Steps for LAC-DMH
Educating ourselves
Developing a clear model for integrating behavioral healthcare prior to primary care integration
Identifying existing models/programs that work
Project-50
AB2034/FSP/Adult Hospital Linkage Project
Santa Monica Dual Diagnosis Project
Others
July 9, 2010
County of Los Angeles – Department of Mental Health
A Primer on Healthcare Reform

9. Healthcare Reform: Getting Ready
Next Steps for LAC-DMH (Con’t)
Implementing new Projects with an eye towards healthcare reform
Innovations
PEI directly operated programs’ collaboration with DHS
Co-location of FQHCs in outpatient clinics
July 9, 2010
County of Los Angeles – Department of Mental Health
A Primer on Healthcare Reform

10. The 1115 Waiver and CEED A Primer on What Lies Ahead for Mental Health
October 13, 2010
Robin Kay, Ph.D., Chief Deputy Director and
Roderick Shaner, M.D., Medical Director
County of Los Angeles – Department of Mental Health

11. The 1115 Waiver and CEED What is an 1115 Waiver?
Plan for a state’s delivery of services to Medicaid (Medi-Cal) and Medicare beneficiaries
Requires approval by the federal Centers for Medicare and Medicaid Services (CMS)
Basis for CMS tracking and auditing of the services provided within a state
Services provided under a waiver must be “revenue neutral”
July 9, 2010
County of Los Angeles – Department of Mental Health
A Primer on Healthcare Reform

12. The 1115 Waiver and CEED What is a CEED?
CEED = Coverage Expansion and Enrollment Demonstration Project
CMS Funds are saved through efficient operation of Medi-Cal under the waiver
Saved funds used as 50% match for defined services to a priority population of uninsured individuals in participating counties
CEED has defined minimum managed benefits package of health and mental health services
July 9, 2010
County of Los Angeles – Department of Mental Health
A Primer on Healthcare Reform

13. Planning for the “New” Waiver
The 1115 Waiver and CEED
Planning for the “New” Waiver
California DHCS implemented a stakeholder process including outpatient providers, hospitals and consumers
Underlying principle: An integrated approach to physical health and mental health care in the community as well as in a hospital setting
July 9, 2010
County of Los Angeles – Department of Mental Health
A Primer on Healthcare Reform

14. The 1115 Waiver and CEED Key Elements of the “New” Waiver
Priority Population
Funding, Revenue and Reimbursement
Service Delivery Models
Coverage Expansion and Enrollment Demonstration (CEED) projects
The Mental Health Benefit - A Three Tiered Approach
Beneficiary Enrollment
July 9, 2010
County of Los Angeles – Department of Mental Health
A Primer on Healthcare Reform

15. CEED Priority Population Childless adults (18 years and older)
The 1115 Waiver and CEED
CEED Priority Population
Childless adults (18 years and older)
Below 133% of Federal Poverty Level (FPL)
Income as the key criteria – not serious and persistent mental illness
Excludes individuals who are undocumented, non-legal residents
July 9, 2010
County of Los Angeles – Department of Mental Health
A Primer on Healthcare Reform

16. CEED Service Delivery Models
The 1115 Waiver and CEED
CEED Service Delivery Models
Primary medical home
Primary behavioral healthcare home
Integrated care
Care coordination
July 9, 2010
County of Los Angeles – Department of Mental Health
A Primer on Healthcare Reform

17. The Challenges Ahead of Us
The 1115 Waiver and CEED
The Challenges Ahead of Us
Developing relationships among DHS CHCs, PPPs, specialty mental health clinics – both directly operated and contracted
Developing a case rate at the end of Year 1
Managing care to adequately treat clients while minimizing risk
Identifying outcome measures that will serve as a basis for healthcare reform
July 9, 2010
County of Los Angeles – Department of Mental Health
A Primer on Healthcare Reform