The Public Policy Committee of the Hammond Commission met at Central State Hospital in Petersburg, Virginia on Friday, July 16, 1999. Members present were Dr. Louis F. Rossiter, Professor at the Medical College of Virginia, Virginia Commonwealth University and Raymond Burmester, Coalition for the Mentally Disabled Citizens of Virginia. Others in attendance included: Charline Davidson, Director of Planning and Regulations for the Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) and liaison to the Committee; Martha Mead, Director of Legislation and Public Relations for the DMHMRSAS; Paul Gilding, Director of Community Contracting for DMHMRSAS; and Jane Hickey, Office of the Attorney General.

Dr. Rossiter, Committee Chairman, called the meeting to order at 10:07 A.M. and made introductions. He announced that he had received information from the Office of the Secretary of Health and Human Services that the Executive Order for the Commission would be extended and a new Chairman would be named.

Ms Kroboth, a parent of an autistic son, said that the Autism Program of Virginia (TAP-VA) was begun in 1996 by family members who wanted information and services for individuals with autism. The mission statement of TAP is "to provide leadership in the implementation of a statewide system of services to maximize the potential, success, and quality of life of each Virginian with autism." The number of autistic individuals is increasing, and there is a wide range of functioning among them. With the assistance of the ARC of Virginia and the Department of Psychiatry at MCV, they received an allocation from the General Assembly that year and again in 1998 to help with education, training, technical assistance, referral, and family support. Allocations for TAP come via the MCV Department of Psychiatry through the Department of Higher Education. Autism is currently not covered by any agency, so TAP coordinates services through existing organizations. Grants have been awarded to the Virginia Treatment Center, the Virginia Institute on Developmental Disabilities, the Virginia Institute of Autism in Charlottesville, and others. Ms Kroboth said that the goals for TAP are:

• Personnel training. There is no university level program in Virginia to train professionals in the field of autism;
• Regional centers of expertise in autism; and
• Ongoing training, support, and respite.

Ms Kroboth introduced Beth Sarrett, Executive Director of TAP-VA.

Ms Jones has a sister who is a resident of the Southeastern Virginia Training Center and is happy with the services that she receives there. Ms Jones is an advocate for improved services and more funding for mental disabilities. She believes that all individuals with mental disabilities should receive services regardless of age, have choices for placement, and have training centers as an available option. If someone is discharged to the community and cannot adjust, they should be allowed to return to the facility. All residents in facilities should have guardians.

Dr. Hurley is a national expert and author on Medicaid managed care. He said that Medicaid managed care has grown significantly in the last four to five years and that 55-60% of the Medicaid population is now in managed care. Most of the enrollment has been among the TANF population, and the inclusion of SSI has been cautious because of the many exclusions, exemptions, and carveouts. There are three program types:

1. Fee for service primary care case management. This includes a case management fee, but no incentives, and exists statewide in Virginia.
2. At-risk primary care case management. This provides partial capitation and is not currently in use in Virginia.
3. HMO / prepaid health plan. This is the dominant form in the country and has full capitation.

Many states have mixed models because of population variables, and there is a growing concern about the impact on safety net providers.

There was not much interest in behavioral health managed care (BMC) initially because of the limited population and amount of money involved. HMO requirements were very modest, and capitation was small. Some states began experiencing difficulty in accessing mental health services when HMOs subcontracted with BMC organizations. States were also concerned that public sector providers would be excluded from the network and lose needed Medicaid money. Concerns about BMC in the public system and whether commercial HMOs had the capacity or willingness to serve individuals with mental illness were raised on all levels. Consumers and advocates mobilized against prepaid managed care, and interest in carveouts grew.

There is enormous diversity in the models currently used within 47 states, influenced by Medicaid and target populations, but there are three general models:

1. Integrated physical and behavioral health. HMO capitation includes limited behavioral health benefits. HMOs may provide services directly or subcontract, and states may set standards and policies for the HMOs.
2. Partial / full carveouts. Some or all behavioral health services may be excluded from the physical health capitation, and states contract directly with a BMC organization for these services.
3. Standalone. Separate entity receives funds from Medicaid and other sources for behavioral health and contracts with regional entities, often providers.

Dr. Hurley discussed the models used by some of the states including Massachusetts, Maryland, and Texas.

He made these observations and conclusions:

• Sound planning, phasing, and sufficient time are necessary.

• Long term impact on consumers and service quality is unclear.
• Sound administrative systems, a commitment to measuring outcomes, and good contracts and contractors are necessary.
• MC models have the potential for obtaining better outcomes, and further study and development are warranted.

Ms Marsh explained that NAMI has studied managed care and taken the position that any model implemented should:

• Ensure good outcomes and accountability;
• Include clear incentives to provide good care and not restrict access;
• Have more integration between primary health and behavioral health care;
• Provide coverage for a full range of core services, including 24 hour access, crisis stabilization, PACT, case management, psychiatrists, new medications, psychosocial, and residential and employment supports;
• View hospitalization as a last resort option; and
• Define the target population as those with brain disorders.

Ms Marsh expressed her concern that Virginia was moving toward a managed care system that would include only 1/3 of the individuals with mental illness, those who are eligible for Medicaid. She wants the general fund money to be leveraged for maximum Medicaid match and additional funds allocated for the system for those who are indigent and not eligible for Medicaid. She is concerned about indigent individuals who are not receiving help and believes that eligibility should be expanded. Ms Marsh said that if the state contracted with an Administrative Services Organization (ASO) to provide such services as prior authorization, discharge planning, and quality improvement monitoring, it would be preferable to contracting with an MCO because the incentive to deny services is removed. However, she doesn’t want the existing service dollars to be used to pay an ASO or any other third party entity.

Mr. Waldron said that the goal for individuals with developmental disabilities/mental retardation was to live a life that was as normal and productive as possible. He listed four Self-Determination Principles for these individuals:

1. Freedom: the exercise of the same rights as all citizens;
2. Authority: control over the funds needed for one's support;
3. Support: services needed as determined by the person with a disability; and
4. Responsibility: the wise use of public dollars to invest in a person's life.

Mr. Waldron expressed his concern about the following issues:

• Individuals with developmental disabilities but not mental retardation are being left out of the system.
• Virginia has a state funded, locally controlled system that doesn't provide accountability. There needs to be more monitoring of the CSBs.
• Virginia's system is institution-based and needs to be shifted more to the community.
• Technical assistance should be provided to CSBs, providers, and consumers and families.
• There is a wide disparity in local government funding for the community-based system.

• Managed care should be considered, however a medical model is not appropriate for MR.
• Flexibility and choice are very important to meet individual needs, but in some cases services are not being provided because the system is underfunded and the Medicaid reimbursement rate is too low.
• Many CSBs are not encouraging private providers.
• Case managers are critical to the system and need ongoing training and a reasonable caseload.

A written report from Diana Thorpe from the Department of Medical Assistance Services (DMAS) was submitted that gave a status update on the development of a Medicaid Home and Community-based Waiver for persons with developmental disabilities. DMAS plans to submit a waiver application to HCFA by January 2000 and offer services beginning July 2000.

Ms Anthony said that only 1% of the mental retardation population need training centers. These profoundly retarded individuals are dependent upon others for their most basic needs, are often nonverbal, medically fragile, and behaviorally challenged. Self-determination is not a possibility for them. Training centers offer managed care to their residents through a primary care physician and professionals trained in the subspecialties necessary to serve this population.

Ms Anthony believes that traditional managed care (MC) would not be appropriate for individuals with profound mental retardation (PMR) because:

• MC is based on holding down costs by controlling treatment options and access to specialists. PMR consumers need specialty care and expensive procedures on an ongoing basis.

• HMOs and primary care physicians do not select this population because they are too expensive and time consuming. Access to ancillary services is inadequate, and the lack of therapy or other services can cause harm.
• MC limits payment for adaptive equipment and may not cover early intervention treatment or the best medications.
• MR consumers require long term care which MC usually excludes, and private providers often decline to treat these individuals.

Ms Anthony made the following recommendations:

• Expand the concept of the "Center of Excellence" piloted at the Northern Virginia Training Center (TC) and, in Phase 1, permanently fund this service as a Regional Community Support Center offering education and training, medical, dental, and behavioral resources and respite services for the community. Phase 2 would involve downsizing the Central Virginia TC and Southside Virginia TC and replicating the model at each facility with additional staff and resources. Phase 3 would expand the model to the Southeastern Virginia TC and the Southwestern Virginia TC.
• Create a carve-out for medical services for those with MR, and include dental services.
• Virginia should develop its own model for MC and begin researching for innovative approaches and workable models used in other places. Ms Anthony suggested a program from the Robert Wood Johnson Medical School to train physicians in health problems associated with developmental disabilities and a physician referral system used in the Boston area to identify physicians who are trained and willing to treat patients with MR.
• It is essential to establish uniform quality assurance standards and monitoring for identified outcome measures with appropriate input from parents / guardians.

Dr. Larry Latham, Director of Central State Hospital, welcomed the Committee and announced some of the recent changes and progress at the Hospital. A forensic program has begun, a psychosocial rehabilitation model has been implemented, and renovations to some of the buildings are underway. They are working on the acute care pilot program for Region 4 that was recommended by the Commission. This is a collaborative effort among the CSBs, private providers, and Central State to maximize existing services and avoid duplication. Individuals with acute care needs will be sent to private psychiatric hospitals instead of Central State.

Katherine Webb, Virginia Hospital and Healthcare Association

Ms Webb said that the Virginia Hospital and Healthcare Association represents hospitals and health systems throughout the Commonwealth. A wide range of service models and programs is available, including integrated delivery systems, HMOs, and outpatient and inpatient services. There are about 50 behavioral health providers in Virginia. She described some of the factors that financially impact private hospitals:

• Inadequate Medicaid rate reimbursement;
• A Federal law requirement for treatment of any individual who comes to the emergency room; and
• The CSB performance contract requirement that patients receive a medical assessment.

Ms Webb introduced the next speakers who represent two private providers.

Presentation: James E. Forrester, ED.D., Sentara Mental Health Management

Dr. Forrester gave a brief overview of the evolution of behavioral health care and the beginning of managed care in the 1980s. Concern over cost in the 1990s created a public backlash, and it was determined that 80% of the cost was consumed by 15% of the patients. The focus became identifying high-risk patients and providing the services they need. Dr. Forrester named some of the identifying factors for high risk, including dual diagnosis, children admitted for psychiatric hospitalization, readmission within 90 days, and psychotic diagnosis. Some of the objectives for treatment should be to prevent readmissions, and psychotic episodes; decrease suicide and non-compliance; and address physical health as part of the behavioral health plan.

Dr. Forrester discussed some of the responsibilities of a managed care company:

• Develop and contract with treatment models to serve this population with a wide range of services to provide appropriate individual care in a timely manner. There are economic and ethical incentives for the managed care company to treat problems before a higher level of care is needed;

• Coordinate treatment planning between providers and facilitate patient access;
• Provide community resources;
• Coordinate and monitor the use of the patient’s benefit;
• Monitor the quality of services and patient compliance; and
• Coordinate behavioral healthcare with the primary care physician.

A copy of Dr. Forrester’s outline is filed with these minutes.

Dr. Breit discussed the collaborative model between the Central Virginia CSB and Centra Health, a not-for-profit private hospital in Lynchburg. She thinks that this model, which has existed for ten years, has been effective and may be useful when designing other public – private partnerships in Virginia. Centra has a contractual agreement with the CSB to provide all emergency services 24 hours a day. They also include a reduced rate for inpatient services for indigent children and adolescents, for BRIDGES, a residential treatment center for children, and for PATHWAYS, an alcohol and substance abuse program. Some of the advantages of this collaboration are:

• All emergencies in the community come to one location;
• All patients receive a medical screening by a physician as well as a mental health consultant;
• Psychiatrists and other specialists are available if needed;
• Medications may be administered during emergency treatment if needed;
• Security officers who can issue TDOs are available, and law enforcement officers are not required to remain with the detained individual;
• Transportation is available; and
• The CSB can direct resources to case management and other community programs.

Dr. Breit said that this system allows more patients to be treated locally, has lowered the commitment rate, and has reduced the utilization of state hospitals. This reflects the recent trends in behavioral health care that has shifted from mental hospitals, both public and private, to a greater utilization of general hospitals and a decrease in the length of stay. Funding sources have also shifted from private to public funding. The effect on the private sector of absorbing more patient care has been increasing costs and more demands on the staff. Dr. Breit said that certain initiatives should occur to assist private hospitals in providing more psychiatric care locally:

• Funding beyond the TDO for committed and voluntary patients to reimburse for care beyond the 48 hour period;
• Funding for partial hospitalization/day programs so the patients can move to less costly treatment with the same team;
• Incentives for CSBs and state hospitals to divert to the private sector; and
• Incentives to private hospitals to provide quality and cost effective care with accountability.

The following recommendations were discussed and will be submitted to the Commission:

1. Local Government Maintenance of Effort: The Code of Virginia should be amended to replace the existing statutorily defined CSB local match requirement with a requirement for local government maintenance of effort funding based on a formula that considers local government ability to pay.
2. POMS Implementation: Recommend continued support for the statewide implementation of the Performance and Outcomes Measures Systems (POMS).

4. Ambulatory Patient Level Data Base Pilot Project: Recommend budget bill language directing the Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) and Virginia Health Information to establish a pilot project to include CSB ambulatory service information in the VHI outpatient patient level data base.

(2.) Study the implementation issues; and

(3.) Examine the effects for one or two willing CSBs.

6. Private ASO Services to Improve Services System Accountability, Efficiency, and Quality of Care: Recommend that the DMHMRSAS receive funding to contract with an administrative services organization (ASO) private contractor for services such as: coverage determination, prior service authorization, utilization management, utilization review, claims payment, discharge planning, clinical necessity reviews, outcomes evaluations, resolution of consumer complaints and grievances, and other services the Commissioner requires.
7. PACE Project Expansion: Recommend budget bill language and $1 million to start-up five new private PACE projects that include formal relationships with community providers of specialized services for individuals with mental illnesses.

 

8. Study of Individuals with Combinations of Mental and Physical Disorders: The DMHMRSAS should conduct a study, which involves the public and private sector and uses VHI inpatient data, of the incidence and geographic distribution of persons with dual diagnoses (i.e., with mental disorders and physical disorders).
9. Autism Study: The Department of Education should conduct a study of the availability and current training programs for professionals treating children, adolescents, and adults with autism.
10. MR Home and Community-Based Waiver Improvements: The DMAS and the DMHMRSAS should continue to cooperate and coordinate to achieve significant improvements in the administration, service array, service delivery, and financial management of the MR Home and Community-Based Waiver. Specifically, the two agencies should review and consider the following:

1. Amending DMAS provider agreements to require private agencies providing MR waiver services to enter into contracts with CSBs. Moreover, the CSBs should develop formal contracts with private agencies providing MR waiver services. The contracts should set out formal expectations addressing service planning, quality improvement systems, reporting requirements, and other monitoring methods;
2. Including wrap-around service definitions and payment methods, such as a daily or monthly rate for 24-hour residential services, that will result in more individualized and flexible supports;
3. Adding to the MR waiver's covered services enhanced dental services (procedures not available under the State Plan dental coverage for individuals with mental retardation whose physical or behavioral issues require specialized services) and a "community guide" service (mentors who provide community connections and natural supports);
4. Significantly enhancing CSB and DMHMRSAS internal quality mechanisms for monitoring MR Waiver services;
5. Documenting existing difficulties in attracting qualified direct care staff for MR waiver services and consider raising payment rates to address problems;
6. Developing and implementing a priority service methodology that is based on an individual's level of impairment and life circumstances and permits individual service funding levels;
7. Ensuring adequate funds to CSBs to provide individual packages of services to persons who are not eligible for the MR Waiver;
8. Providing accommodation in the Medicaid payment methodology to continue payment during a Waiver service recipient's temporary leave from the program; and
9. Considering increasing the earned income limit so that fewer individuals would be limited in their earning capacity and patient pay changes would be less frequent. Study the cost effectiveness of this option for the state budget from shifting more people from state-only funds to Medicaid.

1. Redefine the construction and reimbursement of Medicaid State Plan Option case management service to reflect the intensity and frequency of services provided;

(b) Expand Medicaid coverage for bundled mental health services provided through PACT teams;

2. Add substance abuse targeted case management, day treatment, and residential services for adults who meet diagnostic criteria for drug or alcohol dependence; and

Ms Bergeron presented some of the issues involved in an Administrative Services Organization (ASO) model:

• Suggested ASO functions would be authorization, utilization review, billing, claims payment, data collection and management, eligibility determination, evaluation of outcomes, and consumer contact.
• Care management functions could include assessment, plan development, contract oversight, monitoring of services, and evaluation.
• Services functions would be direct consumer care and treatment.
• CSBs should standardize ASO and care management functions and separate them from service delivery.
• CSBs should maximize choice for consumers and use private providers whenever possible.
• Populations should be defined and managed care technologies incorporated in all functions.

She offered the following options to consider for a system structure:

1. The ASO functions would be provided by a private organization contracted by a public regional entity (HPR or Board). CSBs would provide the care management, and a panel of providers including CSBs would provide the service functions.
2. ASO and care management would be provided by a public regional ASO, and a panel of providers including CSBs would provide service functions.
3. ASO and care management would be provided by CSBs and service functions by a panel of providers including CSBs. This is a standalone model that could work with a large CSB.

The meeting was adjourned at 3:45 P.M.