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Breaking Down Silos: The New Mexico Experience



Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Sally Kroner

Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Sally Kroner



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Breaking Down Silos: The New Mexico Experience Breaking Down Silos: The New Mexico Experience Presentation Transcript

  • 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