Coordinating Publicly Funded Behavioral Health and Physical Health Services: The Massachusetts Experience with A Medical Care Management Model

Coordinating Publicly Funded Behavioral Health and Physical Health Services: The Massachusetts Experience with A Medical Care Management Model Aniko Laszlo, MBA, MA, Project Director NASHP Annual State Health Policy Conference Denver, CO October 14-16, 2007

Learning objectives 1. Discuss important design features and mechanisms of a medical care management model available for • Medicaid-eligible long-term unemployed adults with • Chronic medical conditions and • High prevalence of mental health and substance abuse diseases 2. Discuss utilization, patient outcome, behavioral, and financial measures to gauge the success of the medical care management model 3. Funding source of the medical care management model 4. Lessons learned for policy makers Essential Care Medical Care Management Model – NASHP Conference 2 Denver, October 14-16, 2007

MassHealth is the Massachusetts Medicaid program serving 1 million individuals under multiple medical plans and coverage types. The BH program under the PCC Plan is a carve-out with the Massachusetts Behavioral Health Partnership (MBHP). MassHealth 1 million enrollees Primary Care Other MCOs Clinician Plan (FFS, TPL, 4 plans (PCCP) Seniors) 33% of enrollees 28% of 39% of enrollees enrollees Essential coverage (L-T unemployed individuals; 50,000 enrollees) Essential Care (Medical care management model administered by MBHP; 490 currently enrolled, 963 served in FY07) Essential Care Medical Care Management Model – NASHP Conference 3 Denver, October 14-16, 2007

Massachusetts legal landscape for coordinated publicly funded behavioral health and physical health services (1) Chapter 58, Section 30: • Creates the Health Safety Net Office and Health Safety Net Trust Fund • Establishes demonstration programs for disease management for patients with chronic diseases, substance abuse and psychiatric disorders through enrollment in CHCs and CMHCs • Establishes the Essential Community Provider Trust Fund – Funds will be used to make grant payments to improve hospitals’ and CHCS’ ability to provide community-based care, clinical support, care coordination services, disease management services, primary care services, and pharmacy and management services Essential Care Medical Care Management Model – NASHP Conference 4 Denver, October 14-16, 2007

Massachusetts legal landscape for coordinated publicly funded behavioral health and physical health services (2) Chapter 58, Section 113 • Requires DMH to approve the Medicaid behavioral health care benefit design • Requires DMH to approve policies, protocols, standards, contract specifications, utilization review and utilization management criteria and outcome measurements for behavioral health benefits funded by Title XIX, Title XXI S-CHIP and any MassHealth expansion population served under Section 1115 waivers, including DSS and DYS • Requires the Administration to report to the Legislature before it implements radical changes to the MassHealth behavioral health program Essential Care Medical Care Management Model – NASHP Conference 5 Denver, October 14-16, 2007

Other initiatives supporting coordinated publicly funded behavioral health and physical health services 1. State agency reorganization (EOHHS) – MassHealth Behavioral Health Unit now under the Department of Mental Health 2. System change is initiated via pilot projects at the local level • CHC-CMHC* pilot project for 6 site pairs – coordination initiated by providers • Care management pilot project (Essential Care) – coordination initiated by care managers Lessons learned from local initiatives via program evaluation become recommendations for the state agency to remove barriers (e.g. state regulation, provider reimbursement, system financing, etc). Policy decisions built on lessons learned. *Community Health Center (CHC); Community Mental Health Center (CMHC) Essential Care Medical Care Management Model – NASHP Conference 6 Denver, October 14-16, 2007

Essential Care is a medical care management model providing and coordinating services to individuals with multiple chronic clinical conditions Enrollment requirements • MassHealth members with Essential coverage • Clinical conditions: Diabetes, asthma, substance abuse disorder, other clinical conditions • Frequent service utilization: Inpatient hospitalization, ER visit, visit to a detoxification facility • Treatment and medication non-compliance • Cost: Likelihood of incurring >$20,000 in the next 12 months Essential Care Medical Care Management Model – NASHP Conference 8 Denver, October 14-16, 2007

Important Design Features of the Essential Care Medical Management Model. Program manager is MBHP • Predictive modeling software from McKesson Corp. (Early Case Identification - ECID). MBHP now uses MEDai’s predictive modeling product • ECID assigns general population risk score to each individual in addition to disease-specific risk scores (asthma, diabetes, COPD, CHF and CAD) • CareEnhance Clinical Management System (CCMS) – Care manager support software from McKesson Corp. • Field-based model operating with 12.5 FTE care managers (RNs, LICSWs). Care managers are responsible for coordination of services • Care managers conduct provider outreach to encourage referral to the program • Program Outreach Administrator and care managers conduct member outreach to enroll members Essential Care Medical Care Management Model – NASHP Conference 9 Denver, October 14-16, 2007

Identification of individuals with multiple chronic conditions and behavioral health disorders • ECID uses a mathematical algorithm based on medical and pharmacy claims and other variables to assign risk scores (ECID/MEDai is to include BH claims in the risk score algorithm) • MBHP works in collaboration with MassHealth to review and approve the criteria for the members targeted for enrollment • Other than ECID: – Referral from PCPs and community providers; individuals with conditions not captured by the ECID score identified – Provider outreach by MBHP – MBHP behavioral health utilization management database Essential Care Medical Care Management Model – NASHP Conference 10 Denver, October 14-16, 2007

Beyond ECID, most referrals come from various types of community providers and from MBHP’s Assessment Unit Number of Referrals to Essential Care by Source Other Than ECID Score FY03-FY05 [N=562 records for 374 individuals]* 60 51 50 41 40 # Referrals 30 26 23 22 19 19 20 14 9 10 3 1 1 0 ily t nt P) C nt y se er al nt al is nc PC rn r ie tie th tie S m bu al er (E ge at te O Fa ci pa a ef A p np In pe A y R In ut e nc lf- e P c I S O at H al an H ge Se al B B ic St st ic er M ed b ed Em Su M M Essential Care Medical Care Management Model – NASHP Conference 11 Denver, October 14-16, 2007

Member outreach and care management services tailored to individual patients are key components • Care managers contact potential enrollees and invite them to participate • Care management adjusted to individual patient needs and coordinate services as follows: – Appointment scheduling – Accompany member to medical appointments – Facilitate communication between physician and member – Provide education material on diseases and healthy lifestyle – Connect with social services agencies Essential Care Medical Care Management Model – NASHP Conference 12 Denver, October 14-16, 2007

The work of care managers is assisted by a decision support software (CCMS) • CCMS is an electronic platform for developing the Individual Care Plans (ICP) – Documents treatment processes and client progress – Plans care manager tasks and sends reminders – Incorporates various outcomes tools (SF-12, PHQ-9) and associated variables (Hemoglobin A1c, ED visit) • Provides live access to member eligibility, medical, behavioral health, and pharmacy data via laptop computers in the field • Supports program monitoring and care manager supervision – Interventions, activities, productivity • New features: ICPs are automatically sent to the PCP; data for outcomes measurement reside in CCMS Essential Care Medical Care Management Model – NASHP Conference 13 Denver, October 14-16, 2007

How well does the medical care management model work? Goal of the evaluation: Determine via utilization, behavioral, client outcome, and financial measures how well the medical care management program is serving the needs of its population Methodology: • Evaluation design: Pre- and post design used a control group and assessed outcomes over the same period of time – Essential Care members: N=414 – Control group members: N=1,656 • Control group: selected by using propensity scores • Evaluation period: October 1, 2003 to June 30, 2005 • Criteria for inclusion: 6 month pre- and at least 6 months post enrollment (same population carried over) Essential Care Medical Care Management Model – NASHP Conference 15 Denver, October 14-16, 2007

Methodology cont’d • Diagnostic profile of individuals assessed: CDPS scores* • Data sources: Medicaid Management Information System for medical and pharmacy claims, MBHP care manager database (CCMS)), and MassHealth eligibility data • Financial measure: $PMPM • Client outcome measure: SF-12 score • Behavioral measure: Medication compliance Limitations: • Financial measure does not include program management costs only service costs • Control group was selected based on administrative data only (age, sex, disability, ECID score) • Small sample size reduces the robustness of the findings *Diagnostic profile of the two analysis groups was analyzed by using the Chronic Illness and Disability Payment System (CDPS) scores. Essential Care Medical Care Management Model – NASHP Conference 16 Denver, October 14-16, 2007

Findings: The frequency of mental health and substance abuse conditions was high in addition to chronic diseases in the Essential Care population Characteristics of Essential Care members • Members on average are white, male, mostly English speaking, and between the ages of 40-54, representing all five regions in Massachusetts • High rate of poverty (<100% FPL), lack of stable housing, homelessness, harder to reach by phone, harder to engage in treatment • Diagnoses and chronic disease burden (see next two charts) Essential Care Medical Care Management Model – NASHP Conference 17 Denver, October 14-16, 2007

Most frequent diagnoses for Essential Care members were Psychiatric, Cardiovascular, and Substance Abuse Disorder Chronic Illnesses Among Essential Care and Control Group Members [FY 03- FY 05] 60% 52% 49% 50% 41% 40% 34% 33% 33% 30% 28% 27% 30% 22% 20% 20% 18% 17% 20% 13% 9% 10% 0% al ric e al es y ar em ar us et tin ul t at be on st el Ab c s i ch Sy as te Sk ia lm e y in D ov Pu us Ps nc tr o di vo ta ar as bs er C G Su lN tra en Essential Care Medical Care Management Model – C NASHP Conference Essential Care Control Group 18 Denver, October 14-16, 2007

Median CDPS score for EC members was twice as high (2.46) as for control group members (1.15) % of Individuals by CDPS Score: Essential Care Members v. Control Group Members [FY03-FY05; NEC=414, NCG=1656] 100% 13% 90% 34% 80% % of individuals by CDPS score 70% 44% 60% 50% 40% 57% 30% 43% 20% 10% 9% 0% EC Members Control Group Members CDPS<1 CDPS 1-2.99 CDPS>=3 Essential Care Medical Care Management Model – NASHP Conference 19 Denver, October 14-16, 2007

Average number of visits/year for service users shows significant decline between pre- and post-enrollment into Essential Care Average Number of Provider Visit/Year: Pre- and Post - EC Enrollment [2003-2005] 14 12.9 12 10 # Visit/Year 8 5.6 6 4 2.6 1.7 2 1.3 0.5 0 Outpatient ER Inpatient Essential Care Medical Care Management Model – Pre-EC Enrollment Post-EC Enrollment NASHP Conference 20 Denver, October 14-16, 2007

Individuals on Essential Care had significantly better medication compliance than individuals pre-EC enrollment Prescription Refill Gaps (FY03-FY05) Cases (N=116)* Control Group (N=1572)** Pre- EC During EC Enrollment Enrollment Members Mean Members Mean P Mean with 4 or (median) # with 4 or (median) values** Members with 4 (median) P- more refills of gaps more refills # of gaps * or more refills # of gaps values*** 94 10 (7.5) 64 4 (3) <0.0001 830 13 (7) <0.0001 *Individuals were enrolled in EC for a minimum of 6 months AND enrolled in MassHealth for a minimum of 6 months prior to enrollment into EC. ** Individuals in the control group had a minimum of 6 months continuous enrollment in ***Wilcoxon signed rank test. Essential Care Medical Care Management Model – NASHP Conference 21 Denver, October 14-16, 2007

Client Outcome: Physical functioning (SF-12) improved significantly for individuals aged 40-54 years between their first and last score General US Members with 2 or Members with 2 or population Age group more SF-12 scores* more SF-12 scores score** P value <=39 years 1st score (Mean) Last score (Mean) Mental 34.8 38 NA 0.1411 Physical 43.3 45.2 NA 0.1881 40-54 years Mental 38.5 39.7 50 0.5577 Physical 38.7 42.9 50 0.0002 55+ years Mental 40.0 41.4 51 0.6696 Physical 36.6 39.5 47 0.1926 *There were 70 individuals with 2 scores, 28 individuals with 3 scores, and 6 individuals with 4 scores.* MBHP Essential Care database. FY03-FY05. *General US population SF-12 scores are for age groups 45-54 and 55-64, respectively. Essential Care Medical Care Management Model – NASHP Conference 22 Denver, October 14-16, 2007

$PMPM was $150 (or 19%) lower for post- enrollment than pre-enrollment into EC PMPM For All Invoice Types: Pre- and Post-Enromment into EC and Control Group [FY2003-FY2005] $900 $798 $800 $700 $648 $600 $500 $416 $400 $300 $200 $100 $- Pre-enrollment into EC Post-enrollment into EC Control group Essential Care Medical Care Management Model – NASHP Conference 23 Denver, October 14-16, 2007

Financing of the medical care management model • Administrative and program expenses are contracted separately with MBHP – Maximum allowed administrative and program expenses are $1.5 million since program inception in 2003 • Medical and pharmacy expenses paid fee-for-service by MassHealth • Behavioral health service expenses generated by Essential Care members are covered by capitation payments made to MBHP by MassHealth Essential Care Medical Care Management Model – NASHP Conference 25 Denver, October 14-16, 2007

Lessons learned from Essential Care: Strengths • Given the psycho-social conditions of this population, DM activities have to be complemented with extensive care management to achieve intended program goals: – Referral from providers that have first-hand knowledge about members’ psychological and/or social barriers to treatment – Member outreach to sign up for the program – Care managers’ face-to-face contact with enrollees to help them stay with the program and provide effective coordination of services across state agencies • Sophisticated IT identification and decision support tool (ECID/MEDai, CCMS) help with outcomes measurement. They provide feedback to individual care plans, to policy makers for program oversight, program redesign, and program evaluation Essential Care Medical Care Management Model – NASHP Conference 27 Denver, October 14-16, 2007

Lessons learned from Essential Care: Weaknesses • Are these results attributable to the medical care management model? Rigorous cause-effect analysis has to be conducted to answer such important question. • What is the total cost of the program and what is the rate of return on investment (ROI) for operating a medical care management program for a more acute population? Essential Care Medical Care Management Model – NASHP Conference 28 Denver, October 14-16, 2007

Contact information Aniko Laszlo Center for Health Policy and Research Ph: (508)856-8817 Aniko.Laszlo@umassmed.edu Essential Care Medical Care Management Model – NASHP Conference 29 Denver, October 14-16, 2007

Coordinating Publicly Funded Behavioral Health and Physical Health Services: The Massachusetts Experience with A Medical Care Management Model

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