Behavioral Health Transformation March 15, 2014

1. Behavioral Health Transformation • March 15, 2014 PRELIMINARY WORKING DRAFT, SUBJECT TO CHANGE

2. Today, we face major health care challenges in Arkansas • The health status of Arkansans is poor: the state is ranked at or near the bottom of all states on national health indicators • The health care system is hard for patients to navigate, and it does not reward providers who work as a team to coordinate care for patients • Health care spending is growing unsustainably: • Insurance premiums doubled for employers and families in past 10 years (adding to uninsured population) • Often unnecessary costs are created in Medicaid due to duplication of services and lack of care coordination

3. Current challenges There are many challenges specifically within the current behavioral health system • Prevention • Awareness of available services can be improved • Gaps in services for behavioral health needs (mental health and substance abuse) • Need for additional training programs • Early intervention • Gaps in early intervention services, including crisis intervention • Existing early intervention can be enhanced • Areas for improvement in current referral and awareness programs • Treatment • Gaps in current treatment delivery system (inc. provider training and workforce limitations) • Treatment is not always delivered in a guideline concordant manner • Care integration and coordination is limited • Outcomes are not tracked effectively • Recovery / resilience • There are gaps in the ways providers address recovery and resilience today • Opportunity to improve consistency in existing recovery / resilience efforts • Consumer, peer, family, and community supports are not always leveraged most effectively • Screenings and assessments • Inconsistent screening and assessment process • Need to improve the use of data • Arkansas has a high prevalence of SED/SMI designations

4. Key facts in behavioral health for the Medicaid population • Early facts in Arkansas • Definitions of key terms • “Core” behavioral health spend1: • Includes behavioral health services delivered to the client, (e.g., services for ADHD or depression) • Does not include direct dementia or DD costs, but does includes BH spend from these populations • Halo: • Includes non-behavioral health services (e.g., medical, support services) delivered to people who also use BH services • Total Medicaid behavioral health beneficiaries • ~110,000 recipients • “Core” behavioral health spend (38% IP, 62% OP) • ~$550 M • “Halo” spend • ~$380 M • Pharmacy spend of behavioral health clients (BH and halo)2 • ~$150 M NOTE: Does not include those funded solely from state general revenue. Analysis underway to incorporate broader behavioral health programs 1 Details of BH spend: ICD9 291 – 314 excluding autism (299) and dementia codes in 294, excludes pharmacy 2 Pharmacy includes some spend from some DD and dementia clients that has not yet been excluded SOURCE: 2011 Medical claims for behavioral health diagnosis codes. Does not include pharmacy, crossover or third party liability

5. Behavioral health core spend is concentrated amongst the highest need clients Distribution of clients1,2by cost of core care for behavioral health • Millions of dollars • Youth3 • Adults • 200 52% of total costs are covered by the top 5% of clients • 155 81% of total costs are covered by the top 20% of clients • 53 • Each bar represents: • 5% of clients • ~5,000 clients • 34 • 19 • 41 • 25 • 3 • 45 • 14 • 29 • 11 • 8 • 6 • 5 • 21 • 4 • 3 • 2 • 16 • 12 • 9 • 12 • 6 • 4 • 3 • 5 • 4 • 3 • 2 • 2 • 2 • 1 • 1 • 1 • 1 • 5% least costly clients • 5% most costly clients 1 Includes all clients with at least one core related claim 2 Excludes clients with DD and LTSS because this group is likely to have multiple health home options 3 Youths are clients<21 years of age; Adults are clients ≥ 21 years of age SOURCE: 2011 Medicaid BH claims (ICD-9 291 – 314 excluding 299 and dementia codes in 294), excludes pharmacy and crossover claims

6. Core spend rank (0-5% = top) Adults Diagnostic profiles for adult BH clients by level of core spend Breakdown of diagnoses by behavioral health spend rank for adults in top 50% of core spend • Percentage, Number of clients = 10,303 1 • Schizophrenia • Other • Anxiety / phobia • Bipolar • Adj. Disorder • ADHD • Depression • SA • ODD • Unspecified • PTSD • 0 – 5% • 9 • 6 • 2 • 1,300 • 5 - 10% • 21 • 8 • 4 • 2 • 1,023 • 10 - 15% • 27 • 8 • 6 • 4 • 2 • 718 • 15 - 20% • 33 • 7 • 6 • 2 • 2 • 692 • Majority of top 5% adults have a diagnoses of schizophrenia • 20 - 25% • 30 • 9 • 8 • 4 • 2 • 773 • 25 - 30% • 29 • 7 • 9 • 5 • 2 • 834 • 30 - 35% • 31 • 7 • 6 • 3 • 3 • 2 • 956 • 35 - 40% • 30 • 11 • 7 • 3 • 1,223 • 40 - 45% • 29 • 10 • 9 • 2 • 1,298 • 45 - 50% • 31 • 10 • 8 • 4 • 1,478 1 Excludes clients with DD and LTSS because this group is likely to have multiple health home options SOURCE: 2011 Medicaid BH claims (ICD-9 291 – 314 excluding 299 and dementia codes in 294), excludes pharmacy and crossover claims; each client must have at least one core related claim

7. Core spend rank Youths Diagnostic profiles for youth BH clients by level of core spend Breakdown of diagnoses by behavioral health spend rank for youth in top 25% of core spend • Percentage, Number of clients = 18,605 1,2 • ADHD • Bipolar • Adj. Disorder • ODD • Other • Schizophrenia • Unspecified • Anxiety / phobia • Substance abuse • Depression • PTSD • 0 – 5% • 20 • 28 • 14 • 5 • 2 • 3,321 • 5 - 10% • 38 • 18 • 8 • 5 • 2 • 3,598 • 10 - 15% • 38 • 16 • 9 • 5 • 1 • 3,903 • 15 - 20% • 37 • 17 • 9 • 5 • 1 • 3,932 • 20 - 25% • 35 • 16 • 10 • 5 • 2 • 3,851 • Both ADHD and ODD will be covered by episodes • Over 1,000 clients in top 5% of spend are diagnosed with ADHD or ODD 1 Excludes clients with DD and LTSS because this group is likely to have multiple health home options 2 Youths are clients<21 years of age; Adults are clients ≥ 21 years of age SOURCE: 2011 Medicaid BH claims (ICD-9 291 – 314 excluding 299 and dementia codes in 294), excludes pharmacy and crossover claims; each client must have at least one core related claim

8. Our vision to improve care for Arkansas is a comprehensive,patient-centered delivery system • Focus today • Objectives • For patients • Improve the health of the population • Enhance the patient experience of care • Enable patients to take an active role in their care • For providers • Reward providers for high quality, efficient care • Reduce or control the cost of care • How care is delivered • Population-based care • Medical homes • Health homes • Episode-based care • Acute, post-acute, or select chronic conditions • Five aspects of broader program • Results-based payment and reporting • Health care workforce development • Health information technology (HIT) adoption • Consumer engagement and personal responsibility • Expanded coverage for health care services

9. Potential payment initiatives to address issues within the BH system PRELIMINARY Initiative Description • Focus today 1 Health homes (& link to medical homes) • Deliver integrated care management to facilitate quality care and positive outcomes through: • Ensuring effective treatment of BH conditions • Integrating care coordination across BH, medical, developmental disabilities, and long-term supports 2 Episode-based care delivery • Increase adoption of evidence-informed practices by creating accountability for all services related to a specific BH condition (e.g., ADHD, and potentially ODD, depression and bipolar disorder) 3 Reimbursement adjustments • Modify reimbursement rules to encourage appropriate diagnosis and utilization of services (e.g., placing appropriate time limits on unspecified diagnoses) 4 Reimbursement for new services • Add reimbursement for selected new services that are known to be cost-effective and evidence-informed (e.g., crisis intervention, substance abuse treatment services, medication management and community-based services) 5 Reimbursement for pharmacy (including polypharmacy) • Build on recent work in pharmacy management utilization rules to ensure appropriate use of medications (includes polypharmacy, therapy interactions, and dosage) 6 Policy changes/enabling initiatives • Develop policy changes or initiatives that enable or compliment the payment initiatives (e.g., changes to certifications for all BH providers, specialty certifications, new screenings)

10. Contents • Behavioral health homes • Proposed behavioral health services

11. PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE Health Home Model What is a health home? The Affordable Care Act of 2010, Section 2703, created an optional Medicaid State Plan benefit for states to establish Health Homes to coordinate care for people with Medicaid who have chronic conditions by adding Section 1945 of the Social Security Act. CMS expects states health home providers to operate under a “whole-person” philosophy. Health Homes providers will integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole person. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/Integrating-Care/Health-Homes/Health-Homes.html

12. PRELIMINARY Goals of the behavioral health home • To deliver integrated care management in a manner that facilitates quality care and positive outcomes through: • Providing care coordination • Providing clients with integrated care coordination within and across BH, medical health, developmental disabilities, long-term supports, and other systems • Managing core care delivery • Ensuring effective treatment of behavioral health conditions, including pharmacy effects

13. Health homes must address comprehensive needs of individuals by utilizing a “whole person” and “person centered” approach while ensuring personal choice assurances through service planning and delivery Health homes will provide services that address issues of access to care, accountability, and active participation on behalf of both providers and individuals/families receiving services, continuity of care across all medical, behavioral, and social supports, and comprehensive coordination/integration of all needed services Health homes will provide services that seek to align a fragmented system of needs assessment, service planning, care management, transitional care, and direct care service delivery Health homes must demonstrate the use of health information technology as a means to improve service delivery and health outcomes of the individuals served Guiding principles for health home development

14. Introduction to a health home What a BH health home is… What a BH health home is not… • A behavioral health agency • Extra support for people who need an increased level of care management or who face greater challenges in navigating the healthcare system • Enhanced support for clients who have needs in multiple areas, including DD, LTSS, housing, justice system, etc. • Opportunity to promote quality in the core provision of behavioral health care • Encourage providers to work in teams to improve outcomes for the clients • A way of aligning financial incentives around evidence-informed practices, wellness promotion, and health outcomes • NOT a direct provider of medical services • NOT a gatekeeper restricting a client’s choice of providers • NOT a physical “house” where all health home activities take place • NOT an organization that is required to contract with other providers (e.g., medical providers) to serve their clients

15. The new behavioral health system will be conscious of varying severity of needs as well as intensity of care management required for the different tiers ILLUSTRATIVE • Care managed by health homes • BH client population • Intensive care • mgmt. performed by BHH • Care mgmt. performed by PCMH • Care mgmt. performed by BHH • Recovery • Recovery • Recovery • Health home • Prevention • Prevention • Health home • Prevention • PCMH • BH provider • PCMH • BH provider • PCMH • BH provider • Tier 2 (medium-needs) • BHH required to manage frequent BH services • Tier 3 (high-needs) • BHH intensely manages BH & support services Tier 1 (low-needs) • PCMH care mgmt. adequate for BH care 1IP=Inpatient OP= Outpatient; SOURCE: 2011 Medicaid BH claims (ICD-9 291 – 314 excluding 299 and dementia codes in 294), excludes pharmacy and crossover claims

16. Example profiles of children in different tiers ILLUSTRATIVE Tier 1 client: Ben Tier 2 client: Tom Tier 3 client: Annie • Ben, age 6, has been diagnosed for 1 year with level I ADHD. • Ben’s family is engaged in treatment and he resides with his family including one sibling. • Ben’s performance in school has been average and he meets the typical cognitive development of a 6 year old. • Ben is known to be easily distracted in school, tends to be the class clown, and he has difficulty keeping friends. He is generally friendly but he is often impulsive and socially immature. His teacher has reported some improvement in his behavior over the past few months. • Annie, age 14, has been diagnosed with Bipolar Disorder and presents with oppositional symptoms as well. She has recently started to make suicidal statements. • Annie is currently living in foster care and has been with her current family for 2 years. • Annie has had multiple acute inpatient stays in the recent months due to her suicidal threats. • Annie’s academic performance has also significantly declined over the past 2 years. • Annie’s family service worker and her therapist are considering admission into a psychiatric residential treatment facility. • Tom, age 8, has been diagnosed comorbid for 2 years with depression and ODD. • Tom continues to display very oppositional behavior at home and school which is beginning to impact academic performance and result in disciplinary issues. • Tom’s family is very involved in his treatment, regularly attending family therapy sessions with Tom’s therapist. However, the family has not been successful in implementing therapeutic strategies in the home. • Tom’s parents would like additional supports in the home and teacher supports and education in the school. • Tom’s therapist and his parents agree he does not need to be placed in a residential treatment facility.

17. Example profiles of adults in different tiers ILLUSTRATIVE Tier 1 client: George Tier 2 client: Roy Tier 3 client: Liz • George, age 26, was diagnosed with depression 2 years ago. • George had previously been in a Tier 2 health home but has greatly improved. • George now manages his depression through regular medication appointments and occasional clinic-based therapy appointments; he does not need a case manager. • George is living independently and maintaining a steady job. • Liz, age 44, has been diagnosed with schizophrenia and has substance abuse issues. • Liz had recently been hospitalized and she is currently in a residential substance abuse program. • Liz needs ongoing behavioral health and substance abuse treatment after she discharges from residential treatment. • Liz will also need housing support, assistance with her budget, and help meeting her nutritional needs including meal planning. • Liz has a history with the criminal justice system and is at risk of returning to jail is she relapses. • Roy, age 32, has been diagnosed with depression and drug addiction, but he is on a path of recovery. • During his recovery, Roy experienced a crisis event. He relapsed, lost his job, and lost his apartment. He was undergoing intensive outpatient substance abuse treatment at the time of his relapse. • Roy and his therapist are of the opinion that his recovery would likely be successful if he was provided with the opportunity to enter a partial hospitalization program and had a peer specialist working with him in the community.

18. Tier 2 and 3 clients will receive care management services from health homes Care management activities • Care plan support • Care coordination • Health promotion • Support services • Comprehensive transitional care • Support and enable care plan adherence by providing assistance with referrals, scheduling and getting to appointments, etc. • Regularly check-in with client to understand barriers to plan adherence • Maintain client documentation • Monitor chronic disease indicators and performance metrics • Integration of care plans across systems • Arrange for / provide client-specific health education services • Educate and support client on self-management plans and routine clinical care • Match individuals (and families) to support services and advocate on their behalf for participation • Maintain awareness of and interact with key services to ensure they are meeting client needs • Establish process to ensure prompt informing on unplanned care • Coordinate and share transition planning with relevant coordinators • Provide regular education on client access to services, especially at transition points • Develop crisis intervention plan, including creating options for increased access Text

19. Contents • Behavioral health homes • Proposed behavioral health services

20. We will optimize our system to ensure that behavioral health care… Is family/consumer-driven and person-centered; Supports and promotes evidence-based, recovery-oriented practices that guide service delivery and payment efficiency; Provides customized, culturally and linguistically competent, community-based services; Offers the least restrictive care; Utilizes a team-based approach to treatment decisions to address service needs; and Ensure services are high quality based on data from outcomes and evaluation tools Guiding principles for Behavioral Health system changes • These principles will support our “Triple Aim” of improving health, increasing quality, and lowering the growth of health care costs.

21. 1915(i) and Home and Community Based Services • This Federal state plan option allows states to offer Home and Community Based Services under a Medicaid state plan to individuals who are Medicaid-eligible.1 • With the intent of improving 1915(i) home and community based services, the ACA broadens the scope of covered services and requires services be provided statewide with no waiting lists. • New community and evidence-based practices will be reimbursed through the 1915(i)1 Medicaid funding mechanism • 1915(i) allows drawing down federal funds to support reimbursement of needed services for the first time • Benefits can be targeted to a specific population, services can differ in amount, duration, and scope 1 States have the option to offer home and community-based services (HCBS) as part of the state plan benefits package, as authorized by the Deficit Reduction Act (2005), which added § 1915(i) of the Social Security Act (SSA). Prior to § 1915(i), states could receive federal Medicaid matching funds for HCBS only through waiver or demonstration projects.

22. In addition to care management, the new behavioral health system will reimburse new, tier-specific services to deliver necessary care • New community and evidence-based practices will be reimbursed through the 1915(i)1Medicaid funding mechanism • 1915(i) allows drawing down federal funds to support reimbursement of needed services for the first time • Benefits can be targeted to a specific population, services can differ in amount, duration, and scope 1 This Federal state plan option allows states to offer Home and Community Based Services under a Medicaid state plan to individuals who are Medicaid-eligible.

23. 1915(i) requiresan Independent Assessment and Individualized Care Plan • Requirements • Face-to-face • Determines necessary level of services & supports • Evaluates functional needs • Consults individual as well as family/significant others & treating providers as well as individual • Reviewspatienthistory • Establishes individualized plan of care • Person-centered care plan development • Based on the independent assessment • Developed in consultation with individual, treating providers or others • Identifies necessary home & community based services to be delivered • Should prevent inappropriate care • Beneficiaries must be re-evaluated at least every 12 months to see if service needs have changed • Provider of the services may not conduct evaluation, assessment or care plan development • Integrated • Care Plan • Independent Assessment SOURCE: Medicaid CHIP Program Documentation; www.medicaid.gov

24. Referral This integrated system includes health homes, behavioral health services, independent assessments and care plans ILLUSTRATIVE • BH client population • Independent assessment • Independent Assessment Report • Integrated Care plan • Care mgmt. performed by PCMH1 • Care mgmt. performed by BHH2 • Intensive care • mgmt. performed by BHH • Recovery • Recovery • Recovery • Health home • Prevention • Prevention • Health home • Prevention • PCMH1 • BH pro-vider • PCMH1 • BH pro-vider • PCMH1 • BH pro-vider Tier 2 BHH2 required to manage frequent BH services Tier 1 PCMH1 care mgmt. adequate for BH care Tier 3 BHH2 intensely manages BH & support services • Population by TierCore Spend by tier • Tier 1 - Total: ~90,000 70% youth 30%adult Tier 1 - 79%OP 21% IP • Tier 2 - Total: ~10-15,000 82%youth 18%adult Tier 2 - 83%OP 17% IP • Tier 3 - Total: ~5,000 72%youth 28% adult Tier 3 - 44%OP 56% IP 1 Patient centered medical home 2 Behavioral health home

25. Preliminary: new behavioral health services to be offered • BH client population • Existing Services • Expanded Services • Proposed Services (including 1915i) Tier 1 Tier 21 Tier 31 Clinic-Based • Individual behavioral health counseling • Group behavioral health counseling • Marital/family behavioral health counseling • Multi-family behavioral health counseling • Psychoeducation • Mental health diagnosis • Interpretation of diagnosis • Substance abuse assessment • Psychological evaluation • Psychiatric assessment • Pharmacologic management Includes low needs services +… Home/Community-Based • Master treatment plan • Home and community individual psychotherapy • Community group psychotherapy • Home and community marital/family psychotherapy • Home and community family psychoeducation • Partial hospitalization • Peer support • Family support partners • Behavioral assistance • Intensive outpatient substance abuse treatment • Aftercare recovery services Clinic/Home/Community-Based • Psychiatric diagnostic assessment Includes medium needs services +… Home/Community-Based • Individual life skills development • Group life skills development • Child and youth support services • Individual recovery support • Group recovery support Residential • Planned respite • Residential treatment unit and center • Crisis residential treatment • Therapeutic communities • Health Home services available in Tiers 2 & 3 • Care management (Tier 2) • Intensive care management (Tier 3) • Wraparound facilitation (Tier 3) • Crisis services available to all Tiers1 • Acute psychiatric hospitalization • Mobile response and crisis stabilization • Acute crisis units • Substance abuse detoxification 1Services are cumulative; any service available in Tier 1, will also be available in Tiers 2 and 3. Similarly, any service available in Tier 2 will also be available in Tier 3

26. 2011 (Pre-Reform) Arkansas Health Insurance Coverage Availability Medicare w/ Disability Employer-Based Coverage or Private Plan Income 400% FPL Uninsured: ~500,000 Medicare 300% 300% FPL FPL >60% of all AR children >60% of all AR pregnancies Medicare 200% 200% FPL FPL Medicare Medicare ARKids First B Medicaid for Pregnant Women/Family Planning 133% FPL 100% 100% FPL FPL ARKids First A (Medicaid) (Medicaid) Medicaid w/Disability 65 0 0 10 10 20 20 30 30 40 40 50 50 60 60 70 70 Age Age

27. January 1, 2014 (Marketplaces Operational)Arkansas Health Insurance Coverage Availability Medicare w/ Disability Medicare w/Disability Employer-Based Coverage, Private Plan Income Private Insurance Private Insurance 400% Employer-Based Coverage or Marketplace Plus Tax Credits (sliding scale) FPL 19-26 yrs of age Medicare 300% 300% FPL FPL 150,000 - 200,000 Lives Covered ~$1.5 Billion Estimated New Federal Dollars for Arkansas Medicare 200% 200% Pregnant Women/Family Planning FPL FPL Medicare Medicare ARKids First B 133% FPL 250,000 Lives Covered $1 - $1.5 Billion Federal per Year Medicaid Expansion 100% 100% FPL FPL ARKids First A (Medicaid) Medicaid Expansion (Medicaid) Medicaid w/Disability 65 0 0 10 10 20 20 30 30 40 40 50 50 60 60 70 70 Age Age

28. QUESTIONS

29. THANK YOU