Providers, consumers prepare for Medicaid managed care: as waiver states mull MBHO contracts, providers see promise--and peril.
Subject: Medicare
Managed care plans (Medical care)
Author: Knopf, Alison
Pub Date: 11/01/2012
Publication: Name: Behavioral Healthcare Publisher: Vendome Group LLC Audience: Academic; Trade Format: Magazine/Journal Subject: Health; Health care industry; Psychology and mental health Copyright: COPYRIGHT 2012 Vendome Group LLC ISSN: 1931-7093
Issue: Date: Nov-Dec, 2012 Source Volume: 32 Source Issue: 6
Topic: Event Code: 490 Contracts & orders let; 610 Contracts & orders received Computer Subject: Contract agreement
Product: Product Code: 9105213 Medicaid NAICS Code: 92312 Administration of Public Health Programs
Accession Number: 313161181
Full Text: Medicaid expansion under the Affordable Care Act will, in time, mean that many more people will have behavioral healthcare. But even states that have embraced the expansion are grappling with how to provide the extra services. Many are applying for waivers from the federal Centers for Medicare and Medicaid Services (CMS) to provide these services by contracting with managed behavioral healthcare organizations (MBHOs).

Because MBHOs have to make a profit, there is concern that even as states use them to expand care to more people, MBHOs could reduce rates to providers or reduce services to meet their own financial objectives. In states that have submitted waivers to adopt managed behavioral healthcare, providers have pressed hard to have a seat at the table so that they can participate in the process and ensure that governors and legislatures follow through on delivering strong benefits. In New Jersey, which was granted a waiver in late October, providers have played an active role.

New Jersey agencies "cautious" about speed, scope of changes

The New Jersey Association of Mental Health and Addiction Agencies (NJAMHAA) has been meeting at least every quarter with various health maintenance organizations (HMOs) on integration issues, said Debra Wentz, Ph.D., CEO. Unlike the MBHOs, there is a large disparity among HMOs about their knowledge of behavioral healthcare, said Wentz. The model in New Jersey will probably be an administrative services organization (ASO) that will, at first, not be risk-based, she said. But ultimately, according to the waiver, it will be full risk-based, and then later move to an MBHO.

Whatever company comes in will have to work very closely with the traditional providers who know these services well in order to have good outcomes, said Wentz. Most MBHOs have worked with providers and consumers in other states, she said.


Providers' main concern centers around reimbursements rates, said Wentz, but that's not their only concern. With any MBHO, there will be another layer of administration, which providers often find intrusive. There is also concern about the scope of the Medicaid expansion itself, as so many people come under managed behavioral healthcare so quickly, as is expected to happen under the ACA.

There will be "growing pains," said Wentz. "But we are concerned because this will be growing so fast, and all at once." She would rather see a gradual implementation. "I don't think the key should turn all at once," she said. "If you do things incrementally, you can stay in control."

There's history that justifies these concerns. New Jersey was the first state to have a statewide system of care for children's behavioral health problems, starting 10 years ago, and there were problems, said Wentz. "There were a lot of glitches in the beginning in terms of getting started, like getting bills paid."

So far, there has been a "very good work group process" between the state and providers, said Wentz. "But we have to be cautious and stay on top of things," she said. NJAMHAA advocated strongly for an oversight committee as the plan is implemented, and that will be the "key to success" once the steering committee is reconvened, she said. "We don't know how much of that would go to the general treasury fund," said Wentz. "It's our hope and our advocacy that funds should be reinvested into the system."

A lingering fear: Limited dollars for more care?

Provider organizations are strongly advocating for adequate rates "that don't just cover bare-bones services," said Wentz. You can't keep delivering better services for less."

Some of the principles of managed care will serve the behavioral healthcare system well in terms of "efficiencies" and getting the right service to each client, said Wentz. But to make this happen, providers need to work with the managed care company. While states hope that such efficiencies will stretch Medicaid dollars further, none have yet found a magic bullet that expands access while saving money.

Wentz thinks the New Jersey model--having a behavioral health home--is a good one, with overarching goals that include better quality care, integrated care, and better access to care. But the real driver of the move to manage healthcare in general is the need to manage limited dollars. "There's fewer dollars, and they're not going to raise more funds," said Wentz.

There's a lingering fear that a contract MBHO, which will take a fee for managing care, could cut into funds that should be used for treatment. At present, the fear is just that, said Wentz: "Going into this, everyone has good intentions."

New business and fiscal requirements

Managed Medicaid, for better or for worse, is the direction all states are taking, and providers need to "move with the times," added Wentz. "We're aggressively training our providers to act differently, to function not only clinically but fiscally as a business," she said. Some examples: "For addiction treatment providers who have never billed Medicaid, they are going to have to learn." Providers will also have to learn how to meet credentialing standards needed to participate in a provider network, particularly in addiction treatment, where "they're going to have to meet a higher standard of credentialing in order to be a player," said Wentz.

Providers used to the fee-for-service billing model--getting paid for each service they deliver--will need to work with new business and reimbursement models under managed care, including greater use of performance-based measures. This means providers will need to get patients to follow-up, for example, so outcomes are as good as possible. And outcome measures could go well beyond treatment. Wentz suggested that providers could be responsible not only for making sure a client stays sober, for example, but for many other facets of recovery, including employment. "This is going to be a lot harder for small organizations," said Wentz.

Staffing will be more than just counselors to meet the demand of more patients; providers will also need people who know how to bill, how to market, how to offer various services, and how to keep a program full. For counseling staff, you need to know what your demand will be, said Wentz. "It's not like a temp agency where you can have people come in when it gets busy," she said.

"Holding their feet to the fire"

The advocacy community--and that means consumers, not just providers--is going to have to help in every state that moves to Medicaid managed behavioral healthcare, said Wentz. "We have a very active, loud, and demanding advocacy community in New Jersey," she said. "We've been at the table, we've been at the Governor's office," she said.

But the work is going to get harder. "In terms of holding their feet to the fire, we do have concerns with the waiver," said Wentz. "Right now we think the current leadership is concerned about the population, but the waiver allows flexibility that would enable different players to change everything," she said. With an eye toward the strong monitoring that advocates know will be essential to preserving benefits, she concludes, "We are going to press to be very visible."


MBHOS Look for providers that promote "wellness, recover and resilience," says Pamela Greenberg, president abd of the association for Behavioral Health and Wellness (ABHW), a trade association representing MBHOS. To this end, MBHOS "contract with a wide range of providers and peer support specialists," she said.

What can providers who are used to contracting with states or counties do to prepare for working with MBHOS? Greenberg suggests these steps:

1) Get to know them. "It is important for providers to familiarize themselves with the companies that offer insurance coverage in their state," said Greenberg. "Peruse the websites and get acquainted with what's needed to become a credentialed provider in the networks."

2) Become a preferred provider. check to see if the MBHO offers "preferred provider" status, and consider trying to achieve it, she said.

3) Develop relationships. "Once you are on a provider panel, try to develop relationships with the clinicians that are doing the authorzations and utilization review," said Greenberg. "Get to know people that work for the speciality behavioral health organization."

4. Be Innovative. "The health care delivery system is rapidly changing integrated care appears to be the wave of the future; think about forming partnerships that help move integration agenda forward."

5. Expect payment changes. Instead of traditional fee-for-service, "providers should be prepared for payment based on outcomes or bundled payments," she said.

6. Know the contract. Greenberg urges providers to learn about the requirements that your state has put in the contract with the MBHO, and "know your state's services definitions."
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