Greetings from Washington, D.C. and the 2016 Legislative and Policy Conference of the National Association of County Behavioral Health & Development Disability Directors! Yesterday was a power-packed day – with deincarceration of county jails, the development of county-based certified community behavioral health clinics, mental health for seniors, behavioral health workforce issues, and more on the agenda.
One of the afternoon sessions that caught my interest was the presentation, “Key Developments In the Medicaid Program,” by National Association of Medicaid Directors executive director Matt Salo. He discussed how the average Medicaid director has four (or more) value-based purchasing initiatives underway – ranging from moving more Medicaid beneficiaries to managed care, moving exempt populations to managed care, managed long-term services and supports (MLTSS) initiatives, dual eligible financial integration, and behavioral health integration. This is a key element in the the evolution of Medicaid programs from payers of claims to active purchasers of care. In his presentation, he described value-based purchasing in way that made me chuckle – “really, really easy to say and really, really hard to do.”
Mr. Salo also discussed the challenges for Medicaid directors in addressing the “fire hose of federal regulations” coming from the federal Centers for Medicare and Medicaid Services – new regulations covering Medicaid managed care (see CMS Overhauls Medicaid Managed Care Regulations; Proposes End To IMD Exclusion For 15-Day Stays), home health, transition planning, and 42 CFR (see HHS Proposes Modifying Privacy Rules On Addiction Treatment Records), among others. He was blunt in his assessment that the Medicaid directors question whether all of these new requirements can be met in the (relatively) short time period allowed. He said that part of the issue that Medicaid agencies are facing a chronic shortage of staff – and changing roles for those staff members in negotiating and monitoring these new value-based payment arrangements. Then, there is the fact that average tenure of a Medicaid director is now 17 months. I would assume the former and the latter are related.
Following Mr. Salo’s presentation, John O’Brien, Senior Advisor at the Center for Medicaid and CHIP Services (CMCS), was on deck. He reviewed some current CMS initiatives – including transition planning for the intellectual/development disability (IDD) system to meet the new home- and community-based services (HCBS) waiver requirements, value-based purchasing for supported employment, and conflict-free case management models. He reiterated the importance of states and counties as the administrators of CMS’ policy and regulations – and their interdependent relationship.
My briefing, System Reform, Value Purchasing, & The Future Of Behavioral Health, followed – with a focus on the state of the shift to pay-for-value and the significant strategic implications for all stakeholders. I closed my presentation with some of the specific strategic issues for counties. I think that county commissioners and county executives need to be thinking about four key issues:
- In states that have not expanded Medicaid, the demand for safety net health and behavioral health services for consumers without insurance is likely to increase. The financial wherewithal of non-profit provider organizations (especially smaller provider organizations) to provide free and low-cost services is decreasing along with their margins and financial stability.
- In states that have expanded Medicaid, the role of the county and its safety net is changing. Unless the county is actually managing some portion of the Medicaid dollars, there will be less of a role on health side and an expanding role in improving the social determinants of health.
- For county governments that are providing direct services for consumers, there are challenges to the viability of those services – in terms of unit cost management, technology investments, risk assumptions, and consumer experience.
- Finally, there is an opportunity, and a challenge, for county health and human service agencies to develop a new best practice model for collaboration with health plans. How do the counties synchronize services, i.e., preventing duplication, clearly defining boundaries and responsibilities, and integrating consumer data for care coordination?
For an “on the ground” perspective on this evolution to a value-based health and human service system, be sure to join us on June 8 and June 9 in New Orleans for The 2016 OPEN MINDS Strategy & Innovation Institute. Our keynote speakers bring an “up close and personal” perspective to the issue. Kristopher L. Smith, M.D., MPP, Vice President & Medical Director, Northwell Health Solutions, will be discussing Strategic Diversification In A Time Of Value-Based Care and Philip Oravetz, M.D., MPH, MBA, Medical Director, Accountable Care of Ochsner Health System will present, Taking Risks, Finding Rewards: The Ochsner Accountable Care Organization Strategy. These are two can’t miss perspectives from executives who are leading, and succeeding, in this move to value.