| Agency Description DMAS is requesting funding to secure a contractor for a rate study to evaluate costs related to continued, necessary enhancements of Medicaid Behavioral Health services. The studies requested are intended to help the Commonwealth prioritize potential future investments in the mental health system, as the rate study allows for determination of both rate but then eventually the budget impact or neutrality of any authorized changes. While initial Project BRAVO implementation has brought in some critical services, our system is still lacking critical redesign of community based options for our members.
In alignment with the Commonwealth’s priorities related to the mental health and wellness for children, transitionally aged youth (18-21yo) and families, this proposal focuses all new work around the redesign of that area in our system of care. The base cost to perform a rate study is estimated at $250,000. Each separate component will cost an additional $50,000 per study. The total cost for including all requested rate studies is $850,000.
The request involves several parts which are all strategic aspects of establishing a financially sustainable behavioral health system. These component parts are described below with the rationale for each.
CURRENT SERVICES
1. The Project BRAVO services implemented in 2021 were based on rates developed in 2018 based on 2017 costs. In the intervening five years, there has been substantial inflation as well as a workforce crisis that has affected the cost of care. Stakeholders have strongly advocated for a REBASING of these rates, which not involve changing anything about the service delivery but rather just examine the original costs to the current costs to determine if necessary adjustments are necessary.
NOTE: These services include Applied Behavioral Analysis, Multi-systemic Therapy and Functional Family for youth, Assertive Community Treatment for adults, Intensive Outpatient and Partial Hospitalization Programs, Mobile Crisis Response, Community Stabilization, 23 Hour Stabilization, and Residential Crisis Stabilization Units for all ages
2. There are some services that currently exist in our system that require some “fixes” or “enhancement” without needing to remove the service altogether. These services have some component of the requirement that needs to be updated without removing the service and replacing it with something else altogether. These are considered REDETERMINATIONS as we would be making changes to the expectations of the services that would translate to new rates. These include:
a. Office Based Addiction Treatment (OBAT): This service needs to be altered into a Hub and Spoke model so that members can initiate treatment at a hub provider and then shift to a spoke provider who can provide ongoing treatment. This is a way to improve access to care for Opioid Use Disorder in line with our goals around reducing opioid overdose deaths in the Commonwealth.
b. Comprehensive Needs Assessment (CNA): This is the assessment service required before any member gets one of our community-based services. We need to enhance the rate to include use of evidence-based assessment tools and establish outcome measures associated with our services. This is a minor change with potential for a big impact.
c. Independent Assessment Certification and Coordination Team (IACCT) Assessment: This is the required assessment completed by a clinician to determine whether a youth is eligible to enter residential treatment services. We need to raise expectations for this assessment including use of evidence-based assessment tools and requirements for care coordination activities with local Family Assessment and Planning Teams. This is a critical change related to the goals of the Safe and Sound Taskforce.
d. Outpatient and Intensive In-Home Services for Youth: We currently pay for these services for youth, but the services as they exist do not reflect the costs of integrating evidence-based treatments that have been shown to work. We propose to identify specific evidence-based practices for implementation in both outpatient and intensive in home services. Outpatient services essentially just need an enhanced rate to be established to cover the additional costs of care associated with these types of evidence-based practices. Intensive In Home needs a full redetermination by changing the requirements of the service and creating stronger expectations around practice and outcomes.
e. Review of Therapeutic Day Treatment: This is our only explicitly school-based service for youth in Medicaid and it has a problematic rate and unit structure that has made it impossible for providers to deliver the service. The service was designed before youth with serious emotional problems were mainstreamed out of self-contained classrooms. The service is written as a group-based service but the structure of the school day makes that delivery method nearly impossible and thus providers are having to deliver it as an individual service. This services needs to be redesigned into an evidence-based school services with an appropriate rate and rate structure.
NEW SERVICES
3. We would like the opportunity to assess rates for NEW BRAVO SERVICES focused on CHILDREN, TRANSITIONAL AGED YOUTH (18-21) and FAMILIES. These are services that were recommended in our initial interagency BRAVO Continuum document that laid out the vision for building out community based services. One of our biggest challenges with moving members out of institutions is identifying community-based services to maintain members at home. Our comprehensive crisis system’s success requires that we have high quality services in the community to refer individuals to once their crisis has been contained. The following are our top recommendations to assess rates for so that the Commonwealth can determine priorities for future investments:
a. Multi-tiered Systems of Support in Schools: This is a redesign that would permanently replace Therapeutic Day Treatment. In preparation of implementing free care in school (State Plan Amendment currently under review), this study would define a full range of services for schools to reimburse outside the IEP, including prevention, outpatient level early intervention, more intensive behavioral supports, etc. This is an innovative design for school-based services implemented in a few other states and part of the federal priorities to address the youth mental health crisis.
b. High Fidelity Wraparound Service: This service will innovate intensive care coordination that is family-driven for our youth with highest needs, including those involved in child welfare systems. The implementation of this service is a recommendation from the Safe and Sound Taskforce. This service is a team-based care coordination process that centers on the individual needs of youth and families with locally-available services and treatment planning.
c. Coordinated Specialty Care (CSC) including Early Psychosis Intervention (EPI). These critical services are for a small population of transitional aged youth and include early intervention for youth who are having potential first break psychosis. The services are currently paid for through Community Services Boards (CSBs).
d. Therapeutic Foster Care case management model, relevant to the Safe & Sound Taskforce Recommendations.
e. A specific rate for the completion of the Uniform Pre-Admission Screening Assessment, completed by Community Services Boards. We have encountered significant challenges in attempting to pay for this activity through mobile crisis rates and it would benefit the system for this to have its own definition and rate.
https://dbhds.virginia.gov/library/mental%20health%20services/Basic%20expect-Prescreeners%20rev%2072016.pdf
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| Alternatives considered (must list at least one) The rate analysis and setting could internally be completed with Provider Reimbursement in coordination with Health Economics and Economic Policy to determine alternative payment models for the MCOs to implement, however, this would require considerable PRD time resources. Continue to pay at current rates without assurance of proper methodological accounting for inflation or programmatic need.
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