Blair County HealthChoices

Transcription

1 Blair County HealthChoices Annual Report Fiscal Year County Commissioners Terry Tomassetti, Chair Diane L. Meling, Vice-Chair Ted Beam, Secretary BLAIR COUNTY PENNSYLVANIA Prepared December 2014

2 HEALTHCHOICES HealthChoices is the Commonwealth of Pennsylvania s mandatory Medicaid managed care program administered by the Department of Public Welfare (DPW). This new, integrated and coordinated health care delivery system was introduced by the Commonwealth to provide medical, psychiatric, and substance abuse services to Medical Assistance (Medicaid) recipients. The needs of the high risk populations included in the HealthChoices managed care program requires broad-based coordination to assure appropriate access, service utilization, and continuity of care for persons with serious mental illness and/or addictive diseases. Because of the cross-cutting coordination needs of Medical Assistance recipients, the unique structure of the behavioral health and human service delivery systems administered by the counties, and their over 30 years experience in administering behavioral health services programs, it was determined that county government would be offered the right-of-first opportunity to enter into a capitated contract with the Commonwealth. As of July 1, 2007, Blair County accepted the right-of-first opportunity to manage the local program and entered into a full-risk capitation contract with the Commonwealth. The County formed a 501(c)3 nonprofit corporation called Central PA Behavioral Health Collaborative, Inc. d/b/a Blair HealthChoices, which manages the local program. During Fiscal Year , Blair HealthChoices sub-contracted with a behavioral managed care organization, Community Behavioral Healthcare Network of Pennsylvania (CBHNP). Services provided by CBHNP included care management, provider network development, quality assurance, member services, and claims management. Blair HealthChoices provides oversight and monitoring of all of CBHNP s activities to ensure full compliance with its contract with DPW. As of March 2012, Blair HealthChoices became a Certified Utilization Review Entity and now provides care management for an identified population. County Commissioners Terry Tomassetti, Chairperson Diane L. Meling, Vice-Chairperson Ted Beam, Secretary Current Board of Directors Nancy Imes, Chairperson Kathleen Wallace, Vice-Chairperson Bob Kuntz, Secretary/Treasurer Donna Gority Diane L. Meling Jeff Sefchok Steve Williamson Management Group Amy Marten-Shanafelt, Executive Director Lori Craine, Director of Clinical Services Jeffrey Harvey, Director of Finance DeAnne Belles, Quality Improvement Coordinator Tina Burman, Administrative Assistant Ron Barrett, Clinical Care Manager Kelly Corl, Clinical Care Manager Tera Kelleher, Clinical Care Manager 2

3 Enrollment Blair HealthChoices Eligibility Trend Eligible Members on Last Day of Year FY through FY ,376 22,603 22,578 22,609 21,510 21,243 FY FY FY FY FY FY Categories of Aid: Temporary Assistance to Needy Families (TANF) Assistance to families with dependent children who are deprived of the care or support of one or both parents. Healthy Beginnings Assistance for women during pregnancy and the postpartum period. State Only General Assistance State funded program for individuals and families whose income and resources are below established standards and who do not qualify for the TANF program. This includes the Categorically Needy (CNO) and Medically Needy Only (MNO) groups. Federally Assisted Medical Assistance for General Assistance Recipients Federal and state funded program for individuals and families whose income and resources are below established standards and who do not qualify for the TANF program. Supplemental Security Income without Medicare Assistance for people who are aged, blind, or determined disabled for less than two years. Supplemental Security Income with Medicare Assistance for people who are aged, blind or determined disabled for over two years. 3

4 Member Demographics Other % African American 1, % Caucasian 21, % TANF 8, % At the end of Fiscal Year there were 22,609 Blair County residents enrolled in the HealthChoices Program. Federal General Assistance % Categorically Needy % SSI with Medicare 3, % Healthy Beginnings 4, % Medically Needy % Male 10, % SSI without Medicare 5, % Female 12, % Age 45 to 64 3, % Age 65 and older 1, % Age 00 to 05 3, % Age 06 to 12 4, % Age 21 to 44 6, % Age 18 to 20 1, % Age 13 to 17 2, % 4

5 Services HealthChoices members are eligible to receive in-plan services offered by their choice of at least two service providers as well as additional services that have been approved for use by the Blair HealthChoices Program. In-Plan Services: Inpatient Psychiatric Hospitalization Inpatient Drug & Alcohol Detoxification, Treatment, Non-Hospital Rehabilitation, and Halfway House Psychiatric Partial Hospitalization Services Outpatient Mental Health and Drug & Alcohol Counseling Laboratory and Diagnostic Services Medication Management and Clozapine Support Psychiatric Evaluation and Psychological Testing Residential Treatment Facilities for Adolescents (RTF) Behavioral Health Rehabilitative Services for Children and Adolescents (BHRS) Methadone Maintenance Targeted Case Management Crisis Intervention Family Based Mental Health Services Peer Support Services Mobile Mental Health Treatment Supplemental Services: Drug & Alcohol Level of Care Assessment Drug & Alcohol Intensive Outpatient Drug & Alcohol Targeted Case Management Drug & Alcohol Partial Hospitalization Psychiatric Rehabilitation Children s Services enrolled as Program Exceptions Multi-Systemic Therapy (MST) Functional Family Therapy (FFT) Summer Therapeutic Activities Program (STAP) Autism After School Program 5

6 Utilization Members Served Male 3, % Age , % Age % Age % Age % Age % Female 3, % Age , % Fiscal Year Members Served: 6,520 Total Expenditures: $27,764,501 Expenditures Age , % Male $15,600, % Age 6-12 $7,861, % Age 65+ $132, % Age 0-5 $1,557, % Age $6,294, % Female $12,163, % Age $3,459, % Age $1,465, % Age $6,993, % 6

7 Utilization by Level of Care Members Served Outpatient MH 4, % RTF % BHRS 1, % Community Support Svcs 2, % Outpatient D&A 1, % Fiscal Year ** Other-Supplemental Svcs 2, % D&A Rehabilitation % Inpatient MH % ** Members Served: 6,520 Total Expenditures: $27,764,501 Outpatient D&A $2,227, % Outpatient MH $3,441, % Expenditures RTF $1,723, % **The Other service category is comprised of supplemental services, such as Drug & Alcohol Assessments, Intensive Outpatient, Partial Hospital, Case Management as well as Children s Services Program Exceptions. BHRS $8,255, % Other-Supplemental Svcs $2,325, % Inpatient MH $3,756, % D&A Rehabilitation $1,785, % Community Support Svcs $4,249, % 7

8 Mental Health Diagnoses Members Served Schizophrenia/Psychosis ** Other MH % 3.3% ADHD/Conduct 1, % Depression 2, % Adjustment 1, % Fiscal Year MH Members Served: 5,893 Total MH Expenditures: $23,327,545 Depression $5,274, % Bipolar 1, % Autism Spectrum % Expenditures Schizophrenia/Psychosis ** Other MH $1,437,803 $373, % 1.6% Anxiety 1, % ADHD/Conduct $5,673, % Adjustment $1,986, % Bipolar $3,147, % Anxiety $768, % Autism Spectrum $4,665, % **Other Mental Health disorders include dementia, delirium, organic psychotic or non-psychotic conditions, personality disorders, eating disorders, sleep disorders, tic disorders, child abuse, intellectual disability, mental disorders due to unknown causes, and transient organic mental disorders. 8

9 Drug & Alcohol Diagnoses Members Served ** Other DA % Opioid % Alcohol % Cocaine % Cannabis % Fiscal Year DA Members Served: 1,294 Total DA Expenditures: $4,436,956 Expenditures ** Other DA $752, % Opioid $2,932, % Cocaine $35, % Alcohol $451, % Cannabis $264, % **Other Drug & Alcohol disorders include drug or alcohol psychosis, drug or alcohol withdrawal, amphetamine abuse/dependence, hallucinogen abuse/dependence, inhalant abuse/dependence, sedative-hypnotic/anxiolytic abuse/dependence, and polysubstance abuse/dependence. 9

10 Average Cost per Member Blair HealthChoices Average Cost per Member by Age Group Age 0-5 $5,025 $4,952 $4,778 $5,649 Age 6-12 Age $7,669 $7,249 $7,221 $6,737 $7,609 $7,062 $7,153 $8,169 Age Age Age $3,187 $2,997 $3,461 $2,532 $2,737 $2,799 $2,735 $2,406 $2,934 $2,807 $2,954 $4,311 Age 65+ $541 $967 $1,096 $1,677 Blair HealthChoices Average Cost per Member by Level of Care BHRS $8,380 $8,306 $8,130 $4,528 Community Support Services $2,067 $2,024 $1,995 $2,038 Drug & Alcohol Rehabilitation $5,886 $5,438 $5,656 $7,469 Inpatient Mental Health $7,738 $7,523 $7,584 $7,528 Other-Supplemental Services $1,180 $1,080 $1,417 $1,112 Outpatient Drug & Alcohol $1,835 $2,048 $2,185 $2,018 Outpatient Mental Health $731 $771 $743 $721 RTF $48,708 $52,599 $60,734 $63,822 10

11 Youth Members Served Outpatient 1, % Included in the Youth category are all HealthChoices members under age 18 and all members involved in BHRS or RTF services ** Other-Supplemental Svcs % RTF % Inpatient MH % D&A Rehabilitation % Fiscal Year Youth Served: 2,420 Total Expenditures: $16,460,935 ** Outpatient $1,586, % Other-Supplemental Svcs $315, % Inpatient MH $1,421, % D&A Rehabilitation $271, % Community Support Svcs % Expenditures RTF $1,723, % BHRS 1, % **The Other service category is comprised of supplemental services, such as Drug & Alcohol Assessments, Intensive Outpatient, Partial Hospital, Case Management as well as Children s Services Program Exceptions. BHRS $8,255, % Community Support Svcs $2,887, % 11

12 Quality Assurance Authorization Denials by Quarter Fiscal Years through A service may be denied in full, a lesser amount of the service may be approved, or a different level of care may be authorized. Only a small percentage of authorization requests are totally denied Complaints by Quarter Fiscal Years through Blair HealthChoices closely monitors complaints filed by HealthChoices members. Only a small number of complaints were filed during the fiscal year and each was resolved to the satisfaction of the involved member

13 Quality Assurance Level One Grievances by Quarter Fiscal Years through Members who are dissatisfied with treatment decisions may opt to file grievances to have the decisions changed. There are two grievance levels and an external review process. Additionally, a member may also choose to file a request for a Fair Hearing at any point during the grievance process Level Two Grievances by Quarter Fiscal Years through

14 Terminology ADMISSION RATE The number of admissions into services per 1000 HealthChoices enrollees. AUTHORIZATION A process that is related to the payment of claims by which a provider receives approval from CBHNP to provide a particular service. Authorizations typically limit the number of units and the time in which the service can be provided. If a service requires authorization for payment, the lack of authorization will result in an unpaid claim. CAPITATION A set amount of money received or paid out; it is based on membership rather than on services delivered and is usually expressed in units of PMPM (per member per month) or PMPD (per member per day). Under the HealthChoices program, capitation rates vary by categories of assistance. CLAIMS A request for reimbursement for a behavioral health service. COMMUNITY RESIDENTIAL REHABILITATION (CRR) CRRs are residential programs designed and operated to assist persons with chronic psychiatric disability to live as independently as possible in the least restrictive setting. COMPLAINT A process by which a consumer or provider can address a problem experienced in the HealthChoices program. CONSUMER HealthChoices enrollees on whose behalf a claim has been adjudicated for behavioral health care services during the reporting period. DENIAL A denial is defined as a determination made by a managed care organization in response to a provider s request for approval to provide services of a specific duration and scope which (1) disapproves the request completely; (2) approves provision of the requested service(s), but for a lesser scope or duration than requested by the provider; (an approval of a requested service which includes a requirement for a concurrent review by the managed care organization during the authorized period does not constitute a denial); or (3) disapproves provision of the requested service(s), but approves provision of an alternative service( s). DIAGNOSIS A behavioral health disorder based on DSM or ICD diagnostic criteria. DIAGNOSTIC CATEGORIES Subgroups of behavioral health disorders. This report contains the following groupings: Bipolar Disorders a group of mood disorders that characteristically involve mood swings. This group includes: Bipolar I Disorder, Bipolar II Disorder, Bipolar Disorder Not Otherwise Specified, Mood Disorder, and Mood Disorder Not Otherwise Specified. Depressive Disorders a group of mood disorders that includes Major Depressive Disorder, Dysthymia, and Depressive Disorder Not Otherwise Specified. Schizophrenia and Psychotic Disorders a collection of thought disorders such as Schizophrenia, Schizoaffective Disorder, Schizophreniform Disorder, and Psychotic Disorder Not Otherwise Specified. Anxiety Disorders a group of disorders that includes: Panic Disorder, Social Phobia, Posttraumatic Stress Disorder, Obsessive Compulsive Disorder, Generalized Anxiety Disorder, and Anxiety Disorder Not Otherwise Specified. Adjustment Disorder the development of clinically significant emotional or behavioral symptoms in response to an identifiable psychosocial stressor or stressors. Impulse Control Disorders includes Intermittent Explosive Disorder, Trichotillomania, and Impulse Control Disorder Not Otherwise Specified. 14

15 ADHD and Disorders in Children includes Attention Deficit Hyperactivity Disorder, Conduct Disorder, Oppositional Defiant Disorder, and Disruptive Behavior Disorder Not Otherwise Specified. Other Mental Health Disorders includes Tic Disorders, Learning Disorders, Communications Disorders, and Motor Skills Disorders. Substance Abuse/Dependence Disorders the DSM- IV-TR refers to 11 classes of substances: alcohol, amphetamines, caffeine, cannabis (marijuana or hashish), cocaine, hallucinogens, inhalants, nicotine, opioids (heroin or other narcotics), PCP, and sedatives/ hypnotic/anxiolytics. DSM The Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. This manual provides a diagnostic coding system for mental and substance abuse disorders. ENROLLMENT The number of Medicaid recipients who are active in the Medical Assistance program at any given point in time. FAIR HEARING APPEAL A grievance process through which a HealthChoices member can file a written appeal, to the Department of Public Welfare, regarding a behavioral health care service decision. GRIEVANCE The process by which a consumer addresses a problem with a decision made about his/her behavioral health care service. This may include denial of a service, approving less service than what was requested, or approving a level of care different from that requested. There are two levels of grievances and an external review process. 1st Level Grievance: An issue which is subject to review within 24 hours for urgent care and 30 days for non-urgent care. 2nd Level Grievance: A 2nd Level Grievance may be filed if the member has not received satisfactory resolution to the 1st Level Grievance. The 2nd Level Grievance Committee reviews the issue within 30 days. External Review: An External Review can be requested after the 2nd level Grievance decision. This process is independent from the managed care organization or the primary contractor. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) This is a Federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title II, Subtitle F, of HIPAA gives the Health and Human Services Department of the federal government the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information. MEMBER Eligible Medical Assistance recipients enrolled in the HealthChoices program during the reporting period. MENTAL HEALTH COMMITMENT An involuntary admission into a psychiatric hospital as per the Pennsylvania Mental Health Procedures Act. Also referred to as a 302 commitment. OUTPATIENT REGISTRATION The process by which HealthChoices members are registered with CBHNP to receive specific outpatient services, eliminating the need for pre-authorization. RESIDENTIAL TREATMENT FACILITY (RTF) A self-contained, secure, 24-hour psychiatric residence for children and adolescents who require intensive clinical, recreational, educational services and supervision. UTILIZATION The amount of behavioral health care services used by Medicaid recipients. Utilization is based on encounter (paid claims) information. 15

16 Blair HealthChoices 1906 NORTH JUNIATA STREET HOLLIDAYSBURG, PA