Empire State Plaza, Albany
NYAPRS EXECUTIVE SEMINARApril 28, 2011
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Magellan’s Medicaid Experience
Public sector focus - 60% of Magellan’s Revenue is Medicaid
Manage behavioral health care for 1.5 million Medicaid members for 8 health plans in 12 States through subcontracting agreements
Contract directly in 5 states representing 13 contracts (Arizona, Florida, Pennsylvania, Iowa, and Nebraska), for 1.9 million members
Pharmacy Benefits Administration Experience in 25 States and DC
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All public sector programs are unique but leverage core competencies: Resources & Experience – Dedicated public sector teams
working locally in each State; national experts who provide implementation expertise and ongoing technical assistance/support.
Infrastructure – Specialized BH IT, claims and QI technologies customized for State and Health Plan customers. Focus on outcomes for members and families.
Flexibility- understanding of the unique needs of each State; customized clinical and provider initiatives that address service gaps.
Dynamic Service Array – Track record expanding and enhancing local service delivery systems to focus on community-based programs, peer support, wraparound services and services that promote recovery goals.
Partnership – Collaborative program design and oversight models that engage consumers, family members, providers and other stakeholders in the decision-making process.
Integration – Coordinated approach to physical and behavioral health, including holistic treatment planning and medication management.
Magellan: Medicaid Expertise
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Experience working with persons with SMI; assisting individuals to manage their behavioral health symptomsExperience coordinating and managing the care of persons with a mental health or both mental health and substance abuse diagnosis; and physical health/medical diagnosisCo-location of behavioral health teams with health plans or MCOsData sharing within and across systems to create recipient profilesPartnering with State customers utilizing Section 2703 of the PPACA:
oA state may amend its Medicaid plan to provide for medical assistance to individuals with chronic health conditions who select a provider or health team as the individual's "health home" for the provision of home health services. oDuring the first two years that the State Medicaid Plan amendment is in effect, the federal medical assistance percentage or "FMAP" (the federal government's share of a State's expenditures for Medicaid) is 90%.
Experience with ACO-Like Models
Key elements in behavioral health approach to ACOs/Health Homes:
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Maricopa County, Arizona: oGlobal payments to Provider Network Organizations (PNOs) who are accountable for individual and program outcomes:oPublicly-available on-line ‘dashboards’ promote PNO transparency and accountability
Florida: oSub-capitated payments for outpatient care provided to enrollees in the Prepaid Mental Health Plan (PMHP)
Examples of ACO-Like Models
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Behavioral Health Approaches & Savings
Savings can be achieved through care management approacheso Magellan has achieved savings without reducing outpatient provider
rates by use of peer programs and community supports diverting members from emergency rooms and reducing inappropriate admissions to inpatient care
Savings can be achieved while meeting recovery and wellness objectives, and meeting quality improvement goals
Continuous care management efficiencies within mature Medicaid programso Field care management (6% savings on cost of care in a mature
program)o Targeted efforts in 2 mature programs (5-6% savings on cost of care)
• Reduce readmissions• Decrease inpatient lengths of stay• Decrease residential treatment utilization• Reduce admission to inpatient care
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Collaborating with Providers to Improve Performance Provider Dashboard
o Increase provider accountability and performance o Measure key indicators designed to improve recipient outcomeso Data shared via Web – electronic provider benchmarking improves care
while incurring minimal costs
Performance-based Contracting (PA)o Reward for quality – varies by provider based on level of careo Reduce ALOS, improve outcomes while containing costs
Reward for Quality (IA)o Providers with demonstrated positive outcomes subject to less frequent
review/oversighto Reduces administrative burden on providers, while promoting and
leveraging provider best practices
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Persons with SMI and co-morbid conditions are best served in a BH centered IHH due to unique capabilities and expertise required to treat persons with SMI
Creative and innovative uses of health information technologyo Integrated member service recordo Comprehensive view of member’s past and current medical, behavioral,
and pharmacy serviceso More efficient and streamlined coordination of health services
Superior anticipated outcomeso Improved clinical indicatorso Better experience of and satisfaction with careo Cost savings through reduced ER visits, hospitalizations, and re-
admissions to intensive levels of care
IHH: A Comprehensive Solution
Integrated health homes featuring behavioral health providers as the clinical lead for care
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Barriers to Care Coordination
Primary Care
Behavioral Health
Substance Abuse
Specialists
Difficultykeeping primary
care and bh visits
Issues with transportation
Issues with literacy and
health literacy
Physician’s offices often not set up to care for individuals
with SMI
Anxiety from unaddressed
physical issues
ER/Urgent Care
Hospital Admission
More likely to die by suicide Likely to die 25
to 30 years younger 15% have
diabetes
40 – 60% of those with
schizophrenia are overweight
High prevalence of co-morbidities
Difficulties with
medication side effects
and adherenceINDIVIDUAL CHALLENGED
WITHMENTAL HEALTH AND/OR
SUBTANCE ABUSE
Very low Income / poverty
Surrounded by others with
similar issues
At least 75% smoke tobacco
78% Unemployed
Clinical gaps in care
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Essential Elements of Integrated Health Home
Member engagement
, peer support,
and family support Use of
community resources
Increased access to
care, including
use of telemedicin
eProvision of
basic physical health
services
Outcomes and
accountability
Enhanced provider
coordination /
pharmacy managemen
t
Behavioral Health as Lead
Coordinator
1
2
45
6
3
SpecialtyCare
HospitalCare
Overview
Behavioral health is the gateway to improved health outcomes through this model, leveraging expertise in utilizing peer support, community resources and telemedicine.
Basic primary care functions are administered via the BH team, whether in a CMHC or other BH clinic setting.
The BH lead also coordinates more intensive medical care, including specialists and follow-up from hospital care.
Patient registry tools track outcomes and drive accountability.
1 2 3
4
5
6
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PA HealthChoices/HealthConnections Case Study
“ Develop a best practice in which a behavioral health carve-out (Magellan) and a Medicaid physical health plan in southeastern PA partner together to improve the connection and coordination of care for adults with serious mental illness enrolled in the HealthChoices Medicaid program. “
Value Propositio
n
Serves Medicaid adults diagnosed with schizophrenia, mood disorder, or borderline personality disorder
Two-year pilot program established and monitored by the Pennsylvania Department of Public Welfare
Services include integrated member profile, including pharmacy data, for participants; multiple clinical touch points between physical and behavioral system; community-based ‘navigators’ who facilitate tx coordination
Program Summary
Decreased inpatient admissions and ER visits Member service profile and integrated health/wellness plan developed for each
member Timely notification to prescribers about medical refill gaps
Desired Outcomes
Improved coordination of care:100% of members connected with PCP100% of members connected with appropriate behavioral health services89% made or sustained progress meeting substance abuse recovery goals93% of participants connected to a medical specialist
Utilization changes:BH outpatient utilization increased,ER and inpatient utilization for physical health decreased
Preliminary Results
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Magellan’s Peer Initiatives
Peer experience is valued and integrated at all levels of our Public Sector programs
o Peer specialists work in our care management centers and national team
o Peer-provided services and supports through our provider networko Partnerships with peer-operated organizations in communities we
serveo Promotion of mutual self-help and support groups as a vital resource
for recoveryPeer Support as an evidence-based practice is
implemented through approaches that worko Peer Crisis Navigators help link people to services to prevent ongoing
crisis involvement (AZ)o Peer Connections and other bridger-type programs help people
coming out of hospitals (PA and FL)o Peer specialists trained to provide crisis support (IA)o Peer Support Whole Health – rolling out across all Public Sector
programs. • Currently in place in Maricopa, Pennsylvania, and Iowa.
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Peer Support Whole Health initiative promotes individual success in achieving personal health goals
o Participants set goals to address specific health/wellness issueso Targeted education sessions and activities (walking clubs, phone trees for
smoking reduction, relaxation and stress groups) to assist participants in meeting their goals
o Services billable to Medicaid as peer/family support, living skills, health promotion
Passport to Careo Educates recipients on importance of physical health care, preventiono Tools and techniques to assist recipients in talking with their PCP, sharing
critical BH information such as pharmacy and labs
Continuing commitment to implement across all Public Sector programs
o 250+ peer specialist trained in PSWH in partnership with Appalachian Consulting Group since 2009
o Peer Support Whole Health part of Integrated Health Home pilotso Expect an additional 150 peer specialists to be trained this year
Recovery, Resiliency & Wellness Initiatives Promote Improved Outcomes
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Recovery, Resiliency & Wellness Initiatives Promote Improved Outcomes
Arizona Smokers’ Helpline (ASH)o Provides Medicaid recipients with free telephonic and on-line resources
to stop smoking, which in turn improves overall health outcomeso Includes “Personalized Quit Plan” to help participants meet their
smoking cessation goalso Resources available in Spanish and English
Peer Crisis Navigatorso Implemented in 2010 in Maricopa County – links individuals in crisis to
community outpatient treatmento Used as both step down and diversiono Peer navigators assist those in need, break cycle of repeat crisis
episodeso Contract with a peer organization to provide warm line service
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Recovery, Resiliency & Wellness Initiatives
Youth in Transition - Magellan Youth Leaders Inspiring Future Empowerment (MY LIFE) – AZ, PAo Awardee at NMHCC National Convention 2011o Youth-led initiative in which young people develop their own service
solutionso Improves the systems of care for youth in transition
www.magellanofaz.com website – extensive tools and resourceso Recovery and Resiliency learning center – 10 webinars on diverse
recovery/resiliency topics; four webinars on Peer Supporto Outcomes dashboard showing program performance in key areas
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Recovery, Resiliency & Wellness Initiatives Self Directed Care
o Persons with SMI (Iowa) Person-centered planning, life coaching, individual budgeting, financial
management, expanded provider networks and services Participants work within a “budget” to “purchase” both traditional Medicaid
services and other, non-traditional goods and services that support their recovery and resiliency plans
o Families with Children with Autism (Pennsylvania) Children with a diagnosis along the autism spectrum and their families
received funds to purchase products and services not otherwise covered by insurance
Funds used for activities to encourage interaction with family members/peers. Other families purchased computers and other media to increase their child’s communication skills
Families empowered to take leadership role in their own treatment process Children’s System of Care
o Goal: Maintain at-risk children with families/caregivers, in their communities
o Care coordinated by dedicated clinicians with expertise in children’s issues
o Access to a range of specialized child/family resourceso Joint treatment planning with schools, medical providers, families,
caregivers
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Participation in Maricopa County Continuum of Care on Homelessness Committee:o Multi-agency committee that includes Government representation, agency
members, formerly homeless individuals and advocateso Committee develops strategies to access Federal and local HUD fundso Magellan provides dollar-for-dollar match in the form of case management,
wraparound services to support housing initiativeso Also provides technical assistance in development and submission of
renewal/new grant applications Housing and Urban Development (HUS) Point-in-Time Homeless Count:
o Federally-mandated point-in-time survey to gather data on numbers, characteristics of homeless individuals
o Magellan staff volunteer time to participate in annual surveyo Survey data used to justify additional funding requests, prioritize housing
developmento Includes sub-survey that profiles homeless and chronically homeless veterans
Project Homeless Connect:o Monthly ‘one-stop shop’ that provides immediate access to an array of social
and support services to homeless/chronically homeless individualso Behavioral health assessment and crisis evaluations with clinical professionalso Provided in partnership with local provider agencies that specialize in services
to homeless individuals
Homeless/Housing InitiativesSince 2007, Magellan has facilitated addition of 3,911 new units of subsidized and transitional housing in Maricopa County, AZ – an increase of 15% in total units available
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Project for Assistance in Transition from Homelessness (PATH):o Partnership with AZ Department of Health Services and Southwest Behavioral Health
Serviceso Outreach for homeless individuals not currently engaged in BH services to help them
find treatment and housingo Quarterly meetings to identify barriers, find solutions to increase housing availability o SAMHSA’s national PATH consultant has provided presentations and program
assessment support
Bridge Subsidy Program (BSP):o Collaboration between Magellan, Public Housing Authorities (PHAs) and non-profit
organizationso Provides linkages and housing for persons with serious mental illness using a
Housing Choice Voucher (HCV) systemo Features the Permanent Supportive Housing (PSH) model (a national best practice)
that provides permanent housing, typically rentals, for members.o The BSP provides transitional funding to help eligible recipients until they can apply
for HUD’s Section 8 HCV.o It also applies for additional Section 8 vouchers when they become available
Corporation for Supported Housing, Tempe AZo Multi-agency collaborative that includes Magellan – Federal stimulus funds used for
rent/utilitieso Created, funded and implemented 35 units of permanent supported scattered site
housing for chronically homeless individualso Magellan provides ‘supportive services teams’ to individuals to ensure their ongoing
stability
Homeless/Housing Initiatives
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Preparing to Become a SNP Provider
PCP/Specialty Health Provider Coordinationo Majority of SNP eligible individuals will have complex care needs, both
medical and behavioralo Foster collaborative relationships with PCPs, other specialty systemso Co-sponsor meetings with primary care system to establish common
understanding of challenges and potential solutions
We look to NYAPRS and its member providers to provide input, partnership and guidance during the transition to an SNP system. Areas for consideration include:
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Preparing to Become a SNP Provider
Clinical Documentationo Review existing clinical documentation (initial assessment, treatment
plan, discharge planning documentation) to ensure inclusion of:• Coordination with PCP• Medication management• Recovery and resiliency focus
Technology Competencyo Develop Readiness for Electronic Medical Record requirementso Ensure system has functionality for comprehensive connectivity, data
sharing
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Questions