Published on October 19, 2007
Breaking Down Silos: The New Mexico Experience Sally Kroner, M.D. Psychiatric Consultant for Medicaid New Mexico Human Services Department
New Mexico . . . • Mostly a rural and frontier state with 1.8 million people • Fifth largest state; sixth lowest density • Second largest proportion of American Indians (10%) • Largest proportion of Hispanics (43%)
New Mexico . . . • Third highest proportion of people below the poverty level • Sixth highest Medicaid FMAP in the country (70%) • Highest number of children uninsured; second highest total uninsured (21% in 2005) • Basic behavioral health services are lacking in many smaller communities
“Old” System Problems Resources not coordinated across funding streams No statewide planning across funding streams No commitment to maintenance of basic community behavioral health infrastructure Multiple disconnected single issue advisory groups with different goals
“Old” System Problems Insufficient or duplicated oversight of providers and services with little attention to quality or outcomes No common goals, outcomes or performance measures Boutique providers Exceptions made for some providers
“Old” System Problems Multiple service definitions and multiple rates for the same code Multiple data systems and reporting requirements Providers required to contract with multiple entities Higher administrative costs for providers
New System Goals • Support of recovery & resiliency is expected • Mental health is promoted • Adverse effects of substance abuse & mental illness are prevented or reduced • Customers are assisted in participating fully in the life of their communities • Available funds are managed effectively & efficiently
GOVERNOR BH COLLABORATIVE T SIG Provide infrastructure to support the BH Collaborative, including 20.5 FTE and contract $$ Co-Chairs P. Hyde Communications Team M. Welby HRSA Betina McCracken Congressionally- Collaborative CEO Media relations; Press releases; Legislative briefings; mandated Telehealth Newsletter w/VO; Communications plan; Website Project support STEERING TEAM BHPC VONM Linda Roebuck, CEO Local Collaboratives Assure efforts are coordinated/consistent; troubleshoot; oversee TSIG; identify new funding sources Admin Support LC/Planning Contract Quality & Policy Capacity/Service CBHTR Oversight Evaluation Development Development Contract Housing; IOP/SA; School Success for kids; Provider capacity Performance data Consumer/family Workforce Coordinate Residential Services; CCSS; PTSD Vets, development, development; measurement & definition/guidelines; development & w/BHPC; Planning; Cognitive Disorders & BH needs negotiations, Performance data reporting; funds Legislative process; training; Legislative Early Childhood MH; Primary care interface; management and warehouse; Grants mapping to PMs; outpatient Development priorities; Veteran’s issues; Jail Diversion & Prison Re-entry; monitoring management; Funds evaluation commitment; of a research Consumer/family Crisis Services, Cultural competence; Supported mapping; Rate/payment contracts (incl Collaborative policies agenda; involvement; employment structure TSIG); VONM Telehealth Community Suicide prevention; SA prevention; Gambling; CQM/QI Plan reinvestment BH COLLABORATIVE LEADS HSD/CYFD HSD/CYFD DFA/HSD PED ALTSD CYFD/DOH/MFA HED DDPC HSD Collaborative CEO Collaborative CEO
The Behavioral Health Purchasing Collaborative • Finance & Administration • Human Services • Division of Vocational • Health Rehabilitation • Children, Youth & • Admin. Office of the Courts Families • Mortgage Finance Authority • Corrections • Health Policy Commission • Aging & Long Term Services • Developmental Disabilities • Public Education Planning Council • Governor’s Commission on • Transportation Disability • Labor • Governor’s Health Policy • Indian Affairs Advisor
What’s Happened So Far • On July 1, 2005 ValueOptions (VO) began managing: – Medicaid behavioral health (including pharmacy) – Mental Health and Substance Abuse Block Grants – State General Fund for children and non- Medicaid adults – Community Corrections
What’s Happened So Far • Cross-agency staff workgroups activated (a “virtual department” across agencies) • 15 Local Collaboratives developed (13 judicial districts and a sixth common “region” for 2 Native American populations) • Behavioral Health Planning Council appointed and then reorganized
What’s Happened So Far • Children’s residential treatment services study done, clinical home pilot project initiated to limit out-of-home placements for kids in juvenile justice and protective services • Rate equalization moving forward • Some providers/funding sources moving towards fee for service
What’s Happened So Far • Legislation regarding licensing and credentialing of the professional workforce passed which addresses reciprocity & Native American issues • Many processes now uniform across most agencies and modeled on Medicaid (complaints and grievances, appeals, etc.) • Common Service Definitions implemented (although a work in progress) • Consumers and advocates increasingly involved in high level decision making
Lessons Learned (To date)
Medicaid • Previous model had full integration for Medicaid members at MCO level • Current carve-out means Medicaid members now have an MCO and a BHO • Both physical health and behavioral health providers are able to treat behavioral health conditions • A detailed mixed services protocol is necessary to deal with potential cost shifting
Medicaid • Pharmacy costs are paid by provider type • MCO’s would like to shift atypical antipsychotic costs to VO • VO would like to shift non-psychotropic medication costs to MCO’s • The State has had to intervene to resolve these issues
Medicaid • VO and the MCO’s struggled initially with communication • VO and the MCO’s created a common process for referrals • VO and the MCO’s meet monthly to discuss difficult cases, but there are still “turf wars”
Provider Issues • VO saw early on that rates for psychiatrists needed to be increased • The State allowed rate increases for managed care Medicaid and other agencies and then followed with FFS rates • We have seen a gradual increase in psychiatrists in rural areas in the last 2 years • Previous model did not encourage this kind of State-wide approach
Provider Issues • Providers were not always billing Medicaid if rates were higher for other funding sources • The extent of this practice was not known until all the data was available through VO • Preliminary data shows that in FY 2007 about 10,000 claims totaling $2.9 million were converted to Medicaid from other funding sources
Substance Abuse/Mental Health Integration • Medicaid benefit is very limited—12 hours of outpatient therapy for alcohol abuse for those 21 and older (Medicaid is considering expanding this benefit) • As a result the mental health and substance abuse treatment funding was in silos • Current mental health and substance abuse service systems are separate with different provider requirements, philosophies, etc. • Prior to 7/1/2005 there were some initiatives to require “screening” in both systems
Substance Abuse/Mental Health Integration • The goal is to integrate mental health and substance abuse treatment at the provider level • The Core Service Agency will provide both mental health and substance abuse evaluation and treatment • A common assessment process will require full mental health and substance abuse evaluation (not just “screening”) • There is provider resistance to changing the current model
Legislative Strategies • Success was achieved this year in many areas by speaking with a single voice • Local Collaboratives developed legislative priorities which were incorporated into the Purchasing Collaboratives legislative agenda • As a result, more favorable legislation was passed this year than last
Cross Agency Collaboration • “We’ve always done it this way”—it’s very important to understand why • Right balance between details and big picture • Need the right people at the table • “Shining a light” can make some people want to hide • Everyone has a great deal to learn
In all affairs it’s a healthy thing now and then to hang a question mark on the things you have long taken for granted. Bertrand Russell
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