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brokering a seat at the table
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New Mexico’s Health Care Reform Movement
and Brokering for a Seat at the Table
Ricardo Gonzales, NMPA Diversity Delegate
 
On February 21, 2012 the New Mexico Human Services Department published its Health Care Reform plan for the state of New Mexico. The plan entitled – “Centennial Care: Ensuring Care for New Mexicans for the Next 100 Years and Beyond”  details the state’s plan to integrate medical services with behavioral health services in yet another move to comprehensively redesign the system of care for New Mexicans (see attachment – NM Health Care Reform plan). The visionaries of this plan indicate that the move is only to “further refine and implement its modernization plan” for Medicaid recipients. However, upon close review the system of care is to be totally revamped in light of Federal Government requirements (reference the Affordable Care Act, see CMS-SMDL #10-24 attachment) that behavioral and mental health care be integrated with medical care, and that these requirements be tied to the millions of dollars the state is now receiving and is to receive in the future from the Federal Government as part of this Health Care Reform process. 
The state’s vision is to “build a service delivery system that delivers the right amount of care at the right time in the right setting” through promoting more integrated care, properly case-managing the most at-risk members, paying providers for outcomes rather than process,”  by “up-front financial investment in seeding Medical and Health Homes,” through health literacy with the goal of making members more savvy health care consumers, and through the use of technology in rural and frontier areas of the state to link services. The state will combine the 12 existing federal government waivers (that presently pay for public health and behavioral health services) into a single comprehensive waiver. The state will also reduce the number of managed care companies (that over-see delivery of the various health services….currently eight managed-care companies) to a more manageable number. 
To maximize the integration of the above noted services – the state will “carve-in” all Medicaid behavioral health services (these services currently are “carved-out” of the state’s physical health care system and budget, and managed by OptumHealthNM with expenditures of almost $238,000,000/year; this “carve-in” is to take effect in June/July 2013). It is the state’s belief that as a result of these changes the health of New Mexicans will improve and there will be a corresponding reduction in the spiraling cost of health care. These plans (as well) are supposed to prepare the state for the influx of Medicaid members starting January 2014 from the current 560,000 to 735,000 members (approximately 37% of the state’s population).
Managed care organizations (MCOs) will be challenged to develop robust Patient-centered Medical Homes which will offer primary care, case management, and linkages to community supports as well as health literacy and education to their patients. MCOs will be further challenged to support care integration through the proliferation of Health Homes, targeted first at those Homes that treat behavioral health conditions involving a co-morbid medical condition, and over time, towards others with different chronic and/or co-morbid conditions. Patient-centered Medical Homes and Health Homes will each be required to provide the six services (prescribed by law – ref. CMS-SMDL #10-24; see attachment).  
The crux of the plan as it pertains to clinical services involves care coordination with risk stratification of clinical services, and the development of Patient-centered Medical Homes and Health Homes.
Care Coordination/Risk Stratification: Members’ needs and risk stratification will determine the degree of care coordination. Care coordination will include assessing and identifying each member’s physical, behavioral, functional and psychosocial needs and ensuring timely access and provision, coordination and monitoring of needed services and treatment to maximize patient independence, safety and welfare. The initiation of care coordination is to be performed upon entry into the MCO with an initial screening. Members at this time will be assigned to a risk-stratification group based on their medical and mental/behavioral health status and history. This initial stratification will be based on (but not be limited to) age, diagnosis, treatment history, current needs, the presence of mental health issues/substance abuse, and living arrangements. Members receiving a “high risk” stratification will receive comprehensive assessments to confirm appropriate risk group assignment and to inform the development of a written plan of care. This care planning process will require input from a “care planning/coordination” team. 
Certain events may trigger a secondary review of a patient’s health status and needs. Trigger events may include a family member or provider requesting that a care coordinator complete a comprehensive assessment, or triggers that include changes in diagnosis, hospitalization or any indication that a member needs a comprehensive assessment and or review of prior assessments. Care managers (who will head up these care planning teams) will then develop a care plan that considers the physical, behavioral and social needs of the member. 
The state will develop capitation rate structures based on risk stratification by maximizing the alignment of care coordination intensity with capitation rate for those who are most at risk.  While MCOs will initially be responsible for the care coordination, the state eventually will move care coordination to the “point of service” by incentivizing the proliferation of Patient-centered Medical Homes and Health Homes in urban and rural areas of the state.       
Patient-centered Medical Homes and Health Homes: The state does not define nor describe the characteristics of a Patient-centered Medical Home in their Health Care Reform Plan. It also is not clear if the development of Patient-centered Medial Homes in New Mexico will follow the joint principals and characteristics of a Patient-centered Medical Home as defined by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association. The reader is referred to the following link (http://www.acponline.org/running_practice/pcmh/understanding/what.htm) on the Guidelines for Patient-centered Medical Home (PCMH) Recognition and Accreditation Programs for the above provider medical groups. These guidelines are important because they set the tone for what requirements are needed in these Homes for behavioral and mental health services. 
The plan indicates that the state has already “contractually encouraged its Salud MCOs to work towards the development of Patient-centered Medical Homes” in both urban and rural areas by setting up primary care environments where the patient is surrounded by care coordination and access to community resources. The University of New Mexico Medical Center was recently NCQA (National Committee for Quality Assurance) accredited as the state’s first Patient-centered Medical Home (e.g., 12 of its medical clinics – receiving Level I recognition). However, the standards used by NCQA for accreditation versus those proposed by physician professional groups (cited above) are different and fail to adequately address behavioral health planning. As an example, the American Psychological Association’s has expressed concern over difficulty getting NCQA to agree to a list of behavioral health providers to be included in NCQA’s Patient-Centered Medical Home standards see - http://www.apapracticecentral.org/update/2011/12-08/integration-health.aspx.
Finally, a “Health Home model” is being developed via the care currently provided in Core Service Agencies (CSAs). CSAs are multi-service agencies designated to provide points of entry for children and adults with intensive, primarily behavioral and mental health needs by assuring comprehensive assessments and care, with wrap around and recovery services.   There are approximately 40 CSAs in New Mexico. The Health Home model is being developed in conjunction with the MCOs to address the medical and chronic disease conditions (of these behavioral health patients), and to assure that the six services required by law are also provided. These include comprehensive case management at the point of service, care coordination and health promotion, comprehensive transitional care and follow-up care from inpatient settings, individual and family support, referral to community support, and the use of health information technology to link services.  CSAs must be comprised of multidisciplinary providers skilled enough to complete comprehensive/specialized behavioral and mental health assessments and evaluations as part of the provision of comprehensive care (see CSA attachment).
While MCOs will be required to contract with CSAs and or other core service networks to deliver a range of behavioral health services – CSAs are envisioned by the state to be a major part of the MCO delivery system for behavioral health services. The MCOs will not be permitted to subcontract the management of behavioral health services to a managed risk-bearing Behavioral Health Organization. 
Brokering for a Seat at the Table: Psychology has never been a major provider of mental health services for the poor and ethnically different who are on Medicaid. For various reasons, most of which are financial in nature, a majority of psychologists are not involved in treating these populations – let alone brokering for a seat at the table to garner a professional benefit in working with these populations. However, with Health Care Reform and the implementation of the Affordable Care Act (Pub.L. 111-148) the New Mexico Psychological Association has been told by our counterparts through the American Psychological Association that a “face change” for psychology is imminent. Unless we join along with others in these changes as “stakeholders” we will have less say so about future changes in health care that will impact our profession.
Our profession not has been involved in the planning process of New Mexico’s Health Care Reform plans. State planning dates as far back as 2009 when New Mexico enacted laws to incentivize the development of Medical-home based Managed Care Models. In 2010 a Behavioral Health Planning Committee headed by the state but comprised of outside stakeholders led to the development of a report - the “Strategic Plan: Positioning Behavioral Health for Health Care Reform: A Framework for Action” (NM Health and Human Services, Dec., 2010) that addresses how the state would begin to formulate plans to integrate medical and behavioral health care. 
Then mid-year 2011 the state created an expert behavioral health panel (comprised of four groups of 47 behavioral health experts from around the state – again NMPA was not involved in this process/selection (see Expert Panel listing in Appendices Section – “White Paper Draft”), along with a State Behavioral Health Task Force.  These groups worked to formulate a plan to address Health Care Reform’s Affordable Care Act and future behavioral health and mental health needs of the state. The outcome from these committee meetings (that span the second half of the year of 2011) led to the development of several important documents that can be accessed at http://www.cbhtr.org/bhept.  Most important involves the “White Paper Draft” (August, 2011) that is the basis for the state’s Health Care Reform plans noted (in above attachment) in “Centennial Care: Ensuring Care for New Mexicans for the Next 100 Years and Beyond.”
At first glance the state’s plan with Health Care Reform appears to open the door for psychology to various clinical and employment opportunities. Simply the fact that Medicaid’s population will grow from 20% of the population to approximately 37% of the population is striking. Psychologists could easily be a member of a care planning/coordination health team (teams that are housed either in Patient-centered Medical Homes or Health Homes), as well as (the typical venue) of being a member on a core-service provider network. MCOs will be encouraged to expand primary care integrated behavioral and mental health services both in urban and rural areas. Providers will be paid for the outcomes they deliver. And the care they provide is to be further incentivized with provider use of evidence based practices/best practices. Given the greater skill level required for the complicated nature of this type of care it appears that psychologists have a greater chance to benefit from these reforms when compared with other provider groups. 
Unfortunately, nowhere in the legal definition of establishing community health teams for Patient-centered Medical Homes (ref. ACA. Pub.L 111-148, Sec.3502 42 USC, 256a-1 – see attachment) is the requirement that psychologists be a part of this team. This definition only makes reference to interdisciplinary teams composed of “behavioral and mental health providers”.  For the last approximately eight years SAMHSA  (Substance Abuse and Mental Health Services Administration) has funded New Mexico over $29 million dollars to improve the quality of the behavioral health non-doctoral workforce in rural areas with the use of evidence based treatments while attempting to address New Mexico’s high injury and violence mortality rates, and supporting financially integrated behavioral health care in medical (Federally Qualified Health Center/Rural Health Center) settings most obviously through their substance abuse SBIRCH project (see link http://www.samhsa.gov/Statesummaries/index.aspx and see attachment “Integrating Primary Medical Care and Behavioral Health Services: NM SBIRT Experience). 
The state (along with the support of SAMHSA) has considered integration strategies with non-doctoral mental health providers in primary care setting who would treat both mental disorders and the behavioral components of medical disorders (see report – “Evolving Models of Behavioral Health Integration in Primary Care at http://www.cbhtr.org/bhept, and attachment “Introduction to Effective Behavioral Health in Primary Care).   These same integration issues are discussed by the Centers for Medicaid and Medicare Services (CMS) but from the vantage point of financing non-doctoral integrated behavioral health care. CMS tells the state (see attachment CMS-SMDL #10-24, p.6-8 under Payment Methodologies and Provider Infrastructure) that the Act (ACA Pub.L. 111-148) permits considerable flexibility in designing payment methodology and models of payment to provider groups in these settings.
The above discussion reminds me (“somewhat reactively”) of the strides that Psychology has made legislatively at a Federal level involving Medicare both with payment issues and with independent practice issues at a doctoral level. Only Clinical Psychologists are able to bill Medicare with the Health and Behavior Codes in Federally Qualified Health Centers/Rural Health Centers (FQHC/RHC). In FQHCs/RHCs in New Mexico (at least currently) only clinical psychologists and clinical social workers are considered primary care (behavioral health) service practitioners who are able to bill Medicare for their services. No mental health provider group other than psychologists can bill Medicare/Medicaid for psychological/neuropsychological testing. And finally while clinical psychologists, clinical social workers, and psychiatrists can bill Medicare with traditional codes outside of primary care environments – no other mental health provider group can (see Medicare Claims Processing, Ch.9, 20.1).
For many years psychologists have practiced in hospitals, medical clinics and primary care settings.   Psychologists have left impressive marks in New Mexico with their work in primary care environments such as the Veteran’s Administration (Albuquerque), in Indian Health Service Hospitals and medical clinics (throughout the state), and Hospital based settings such as Memorial Medical Center (Las Cruses), along with numerous other examples where psychologists are integrated and or co-located in medical and other primary care environments.
Suggested Brokering Strategies: Now more than ever is the time to broker for a seat at the table. The future of our profession depends on these efforts. And although late in the process - NMPA is beginning to communicate with state leaders (e.g., the Honorable Mary Kay Papen, D-Dona Ana county recently awarded APA’s Legislator of the Year) and stakeholders who have been involved with Health Care Reform from the start (e.g., the Primary Care Association of New Mexico, and UNM’s Consortium for Behavioral Health Training and Research) both to talk about our expertise in primary care, and to see how we might join them in the process of the state’s “Centennial Care” plan.  There also have been various primary care experts we have spoken with from outside of New Mexico (e.g., researchers at the Veteran’s Administration looking at outcome studies of their National Primary Care Mental Health Integration Program, and Drs. Runyan and Blount at the University of Massachusetts Medical School who have developed a 36 hour “on-line curriculum” to prepare already licensed providers in primary care, etc.). As always - I also encourage your participation in these NMPA endeavors.  Please let me know about your own interests/concerns about Health Care Reform/Accountable Care Act implementation process impacting your business. If there is enough interest maybe it would be useful to create a committee that seeks to broker specific changes that are on the horizon with integrated medical and behavioral health care (e.g., fee-for-service arrangements, service payments of patients both on Medicare and Medicaid, or issues related to educational/training requirements in primary care or additional behavioral health specialization in primary care).   I can be reached at rgonzales@dishmail.net.
REFERENCES:
New Mexico Health and Human Services – see the 2010 Plan, Positioning Behavioral Health for Health Care Reform: A Framework for Action FY11-FY14 at http://www.bhc.state.nm.us/pdf/Final%20Strategic%20Plan%209Dec2010.pdf, Dec.2010.
 
 

 

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