Providers, consumers prepare for Medicaid managed care

Medicaid expansion, for states that elect it under the Affordable Care Act, will mean a dramatic increase in the number of people having access to behavioral healthcare. At the same time, however, states are grappling with how to provide the extra services, and 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 are for-profit organizations, there are always concerns that even as they expand care to more people, they might also reduce provider rates or service options. So in states that have submitted waivers to go to managed behavioral health care, it’s important for providers to have a seat at the table so that they have a voice in the MBHO contracting process.

In New Jersey, which was granted a waiver in October, providers know that even when they get a seat at the table, they’ll have to remain vigilant. Governors and legislatures can change, and while there is commitment now to preserving strong benefits, this can change in the future.

New Jersey's Medicaid waiver approved

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, she 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 around payment, said Wentz. “If rates are not sufficient to get the services that are needed, that is a problem,” she said. In addition, there will be another layer of administration, which, as providers around the country can attest when it comes to insurance companies, can be intrusive.

Finally, there is concern about having so many people come under managed behavioral health care 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.”

Concern:  Limited dollars, more care

Providers 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 these efficiencies happen, states and providers alike need to work with the managed care company. Too often in the past, improving efficiency has meant saving money, period. Is there a magic bullet that is working well, in terms of expanding access under Medicaid? Nobody knows the answer yet. Do you have to move to managed care to have integrated care? Not necessarily. But managed care is coming, and providers can’t pretend otherwise.

Wentz thinks the New Jersey model – having a behavioral health home – is a good one. Its overarching goals include better quality care, integrated care, and better access to care. But the real driver of the move to managed healthcare is the need to manage limited dollars. The same is true for behavioral healthcare. “If there aren’t enough dollars, they’re not going to try to raise funds,” she said.

Managed Medicaid, for better or for worse, is the direction all states are taking, and providers need to “move with the times,” said Wentz. “We’re aggressively training our providers to act differently in fiscal terms,” she said. “For addiction treatment providers who have never billed Medicaid, they are going to have to learn.” Providers will have to learn how to meet credentialing standards for being in a provider network. This is particularly true in the addiction field, where “they’re going to have to meet a higher standard of credentialing in order to be a player,” said Wentz.

To satisfy the needs of managed care, providers “must be able to function not only clinically but fiscally, as a business,” said Wentz. Providers are used to fee for service – getting paid for each service they deliver. With managed care contracts, however, performance-based measures will play a greater role in compensation. This means providers may need to follow up more closely with patients to assure the best possible outcomes.  And the outcomes won’t be strictly related to treatment, either. For example, said Wentz, providers will be responsible not only for making sure a client stays sober, but for many other facets of recovery, including employment. “This is going to be a lot harder for small organizations,” said Wentz.

Staffing changes will involve more than just counselors to meet greater patient demand. Providers will also need people who know how to bill, how to market the program, how to deliver a range of 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.

Thoughts, advice from MBHOs

MBHOs look for providers that promote “wellness, recovery and resilience,” says Pamela Greenberg, president and CEO 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? “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.” Check to see if the MBHO offers “preferred provider” status, and consider trying to become one, she said.

“Once you are on a provider panel, try to develop relationships with the clinicians that are doing the authorizations and utilization review,” said Greenberg. “Get to know people that work for the specialty behavioral health organization.”

“Be innovative,” urges Greenberg. “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 the integration agenda forward.”

And Greenberg warns that providers need to change their payment expectations. “Providers should be prepared for payment based on outcomes or bundled payments,” she said.

Finally, she urges providers to earn about the requirements that state has put in the contract with the MBHO, and “know your state’s services definitions.” 

A more visible role for advocates

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. “We are going to press to be very visible.”