The Joint Medicaid Oversight Committee (JMOC) had a lengthy discussion on May 26th regarding alcohol and drug addiction. During the meeting, which featured a panel of experts in the field, there were two main points of conversation. First, there was a “status update” by Dr. Mark Hurst, Medical Director of the Ohio Department of Mental Health & Addiction Services (ODMHAS), on the Behavioral Health Medicaid Redesign. Second, there were presentations from a number of guests representing providers and the county ADAMHS Boards.
BEHAVIORAL HEALTH REDESIGN
As we have talked about previously, there are significant changes taking place with the way community behavioral health is being delivered in Ohio. On a larger scale, the carve-in of behavioral health into managed care represents a fundamental change in the way that services and benefits will be delivered in the state. Where once a network of community providers had billed the Ohio Department of Medicaid (ODM) directly on a fee-for-service basis, now providers will have to contract with managed care plans to be reimbursed for services. This shift has huge operational implications for providers as they try to figure out the new, more complex world of insurance contracting, utilization management tools implemented by plans (such as prior authorization), and care coordination oversight as provided by the plans. Certainly, as the state finalizes the contractual arrangement between the plans and ODM, advocates and providers should pay close attention to the provisions of the agreement as they negotiate this new world of delivering service as it will be the basis of the new delivery system. With that said, it is the new reimbursement methodology, not the carve-in, which was the basis of most of the conversation during the meeting.
After his brief update, Dr. Hurst and Angie Bergefurd, assistant director for community programs and services with ODMHAS, fielded questions from a number of committee members about the changes being made to the reimbursement system for community providers. Concerns ranged from insufficient rates, to provider education, to anxieties about attracting and developing a workforce sufficient to meet the needs of patients. In response, ODMHAS explained that the purpose of these changes was to provide transparency to broad case management services, particularly that of Community Psychiatric Supportive Treatment (CPST), by increasing the amount of evaluation and management codes from 18 to 89 (with modifiers) and adding 83 lab and vaccine codes. The state wants to add this level of code detail as well as more granularity about the professional types able to bill, she explained, in order to deliver the most efficient and effective services for patients. Moreover, they explained, an additional $39M was added above the previous “budget neutral” model (up from the most recently reported $37M) in order to allow for some flexibility during transition, including $10M for services for children. ODMHAS, in collaboration with the Department of Medicaid (ODM), has also implemented regional trainings and has engaged in conversations directly between providers and their contracted actuary (Mercer) in order to develop rates in ways that reflect the concerns of providers in clinical settings.
At this point, it seems a final draft of rates will be reviewed by the state’s Redesign Workgroup in mid-June with changes likely delayed past the planned July 1st deadline. This group has been meeting since last spring and continues to inform the evolving work of the state as they implement these reforms. For the most current information, I would recommend checking out Ohio’s splash page for this work and sign up for the state’s newsletter. Additionally, I would advise advocates and providers to pay close attention to the state’s work around episodic-based treatment, which will likely replace a system of discrete codes to a set of codes with a single overall payment. While at first blush that may seem to be undoing the work the state is doing with its expansion of codes today, the expansion may in fact serve as the basis for defining a very complex set of services that would serve as the basis for a “behavioral health episode” tomorrow.
MEDICAID EXTENSION (AGAIN)
After the lengthy discussion on the redesign, the panel moved on to presentations regarding addiction and how each of their organizations try to impact the overall outcomes of Ohioans struggling with addiction. This included a medical explanation of the origins of addiction as presented by Dr. Hurst to specific reviews of programs provided by community providers such as those working with addicted mothers (an especially important topic given the recent Ohio Department of Health report showing one in five newborns admitted to hospitals had symptoms of withdrawal). With that said, I wanted to explore one topic that came up in nearly every presentation: Medicaid expansion.
For ADAMHS Boards, as Cheri Walter of the Ohio Association of County Behavioral Health Authorities explained, the expansion freed up funding for Boards to focus on non-Medicaid services such as housing, employment, and residential services. As Kay Spergel of Mental Health & Recovery for Licking and Knox Counties explained, expansion guaranteed program funding for the next decade where, in the year prior to expansion, they were faced with an $800k budget deficit and service cuts even with levy support.
The takeaway here is that advocates concerned with behavioral health are well-advised to understand not only the impact expansion has had on their patients and outcomes, but also how it has impacted their overall service delivery models. As the state examines policies surrounding expansion, whether that’s through the Healthy Ohio waiver (which does not exempt persons with Serious Mental Illness), personal responsibility measures baked into future legislation, or generally in the context of the shift toward value, policymakers are looking for a return on the political and financial investment. Advocates, then, are well advised to look not just at the direct impact that coverage has had, but at the indirect effects as well.