Compromised Controls and Pace of Compromised Controls and Pace of - - PowerPoint PPT Presentation

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Compromised Controls and Pace of Compromised Controls and Pace of Change Hampered Implementation of Change Hampered Implementation of Enhanced Mental Health Services Enhanced Mental Health Services A presentation to the Joint Legislative A

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Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Compromised Controls and Pace of Compromised Controls and Pace of Change Hampered Implementation of Change Hampered Implementation of Enhanced Mental Health Services Enhanced Mental Health Services

A presentation to the Joint Legislative A presentation to the Joint Legislative Program Evaluation Oversight Committee Program Evaluation Oversight Committee August 2008 August 2008 Yana Ginburg Samberg, Senior Program Evaluator Yana Ginburg Samberg, Senior Program Evaluator

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2 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Enhanced Mental Health, Enhanced Mental Health, Developmental Disabilities and Developmental Disabilities and Substance Abuse Services Substance Abuse Services – – Phase I Phase I Team Team

Yana Samberg, Evaluation Lead

  • E. Kiernan McGorty, Senior Program Evaluator

Carol Ripple, Principal Evaluator Carol Shaw, Principal Evaluator Pamela Taylor, Program Evaluation Statistician

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3 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Evaluation Scope Evaluation Scope

  • Evaluation directed by Program Evaluation

Division 2007-2008 Work Plan

– Approved by Joint Legislative Program Evaluation Oversight Committee December 5, 2008

  • Conduct a process evaluation of the

implementation of the Enhanced Service Package

– Compare implementation plans versus actual events

  • Mental Health Phase II evaluation to focus on

service outcomes

– Report due by end of long session

Report Page 2

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4 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Overview Overview

  • Mental Health Reform legislation passed in

2001 to transition from institutional to community based care

  • New service array implemented in early

2006 aimed to broaden spectrum of care

  • High utilization of individual community

support services were unanticipated

  • Lack of benchmarks, alerts and information

management hindered oversight

  • Recommendations focus on improving data

analysis & strategic information management

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5 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Background Background – – Key Players Key Players

  • Centers for Medicare and Medicaid Services (CMS)
  • Department of Health & Human Services (DHHS)
  • Division of Mental Health, Developmental

Disabilities & Substance Abuse Services (DMHDDSAS)

  • Division of Medical Assistance (DMA)
  • Value Options – private, third party utilization

review contractor

  • Local Management Entities (LMEs)
  • Providers
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6 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Background Background -

  • Enhanced MHDDSA Services

Enhanced MHDDSA Services

  • Services supposed to be evidence

based, clinically proven, science based, and outcome focused models of best practice (HANDOUT)

  • Offer greater range & depth of care

across disability groups

  • Approved in December 2005 &

implemented in March 2006

Report Page 5

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7 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Community Support Services Cost More Than Community Support Services Cost More Than Other Enhanced Services Other Enhanced Services

Source: Division of Medical Assistance – Date of Payment for Medicaid Claims

Report Page 6

$0 $10 $20 $30 $40 $50 $60 $70 $80 M a r c h

  • 6

M a y

  • 6

J u l y

  • 6

S e p t e m b e r

  • 6

N

  • v

e m b e r

  • 6

J a u n u a r y 2 7 M a r c h

  • 7

M a y

  • 7

J u l y

  • 7

S e p t e m b e r

  • 7

N

  • v

e m b e r

  • 7

Millions

CS -Child CS Adult Other Enhanced Services

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8 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Background Background – – DHHS Actions DHHS Actions

  • Audit 167 providers & review of 12, 000

records

  • Reviews found 36% of Community

Support services not medically necessary

  • DHHS actions:

– Freeze on new providers – New service definition – Recoupment of payments

Report Pages 7-8

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9 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Finding: The pace and scope of Finding: The pace and scope of implementation contributed to implementation contributed to

  • ver
  • ver-
  • utilization

utilization

  • Delay in federal approval of new services

unanticipated

  • After federal approval, NC had only three

months to implement new services

  • Implementation marked by multiple policy

revisions, new legislation and new responsibilities

Report Page 8

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10 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Enhanced Services Implementation

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11 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Finding: Delay in determining who Finding: Delay in determining who would provide authorization for would provide authorization for services led to lack of front end controls services led to lack of front end controls

  • Value Options not fully operational until

summer of 2006

  • Authorization requirements initially relaxed,

no ability to track utilization until after services provided, claims filed

  • Lag in claims data = four to six weeks

Report Page 10

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12 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

  • Department surprised by rate of increase in

service utilization

  • Department’s lack of prior experience with

public/private model of service delivery & reform made forecasting challenging

  • Financial data used to develop new service

package not intended as projection of demand

Finding: During implementation Finding: During implementation DHHS did not forecast costs, capacity DHHS did not forecast costs, capacity

  • r utilization
  • r utilization

Report Page 12

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13 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

High Level Expenditure Tracking High Level Expenditure Tracking

$0 $10 $20 $30 $40 $50 $60 $70 $80 $90 Mar- 06 Apr- 06 May- 06 Jun- 06 Jul- 06 Aug- 06 Sep- 06 Oct- 06 Nov- 06 Dec- 06

Millions

Practioner- Non Physican Clinics Mental Health

Because high level budget lines behaved as expected, drill down to specific services was not done. Inset shows breakdown of expenditures by individual service.

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14 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Expenditures by Individual Service Expenditures by Individual Service

$0 $10 $20 $30 $40 $50 $60 $70 $80 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Date of Payment M illions

CS -Child CS Adult Other Enhanced Services

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15 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Finding: Data transfer problems prevented Finding: Data transfer problems prevented authorization and claims reconciliation authorization and claims reconciliation

  • Improper filing of authorization requests and

duplicate requests hampered ability to conduct efficient reviews

  • System communication problems impeded

matching authorization requests with claims data

  • LMEs should have had access to Medicaid

claims data from March 2006

– Access granted April 2007

Report Page 13

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16 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Finding: Program information not Finding: Program information not communicated clearly or communicated clearly or effectively effectively

  • Department collects a tremendous

amount of data

  • Lack of benchmarks, thresholds, alerts
  • Data presented tends to be of a technical
  • r descriptive nature that lacks synthesis

and interpretation

Report Pages 14-15

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17 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

NC Division of MHDDSA NC Division of MHDDSA

Community System Progress Report tracks system performance against set targets as of SFY 07-08 using select performance indicators

Menu of reports & data collected about mental health care in NC

http://www.ncdhhs.gov/mhddsas/statspublications/reports/index.htm

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18 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Recommendation 1: Recommendation 1: Reevaluate data & reporting Reevaluate data & reporting processes while assuring linkage & accessibility to processes while assuring linkage & accessibility to supporting data, reports supporting data, reports

  • Review how information is presented
  • Review number and format of reports
  • Balance executive & legislative

leadership’s ability to access high level summary information as well as more detailed reports

Report Page 17

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19 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Florida Department of Children & Families Florida Department of Children & Families

  • Performance indicators

defined

  • Can look at program

performance by performance indicators, programs, geography, etc

  • Dashboard provides point &

click access based on user needs in variety of outputs

http://dcfdashboard.dcf.state.fl.us/

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20 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

Recommendation 2: Recommendation 2: Require DHHS to redirect

Require DHHS to redirect the mission of the Quality Management Team the mission of the Quality Management Team within the DMHDDSAS within the DMHDDSAS

  • Focus division wide internal analyses

within single office

  • Enable prioritization of information

gathering and data analysis

  • Ensure data consistency, strong analytical

capacity, and consistent reporting

Report Page 18

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21 Program Evaluation Division Program Evaluation Division North Carolina General Assembly North Carolina General Assembly

The Way Ahead The Way Ahead

  • Department should consider broader

application of recommendations beyond the Division of MHDDSAS

  • Develop dashboard reporting system

– See Florida Department of Children and Families as an example

  • Continue to develop knowledge

management based decision making process

Report Page 19