Magellan Behavioral Health of Pennsylvania, Inc., a Medicaid managed care organization (MCO), started as the new HealthChoices behavioral health exclusive contractor for the Cambria County Behavioral Health Services Program on July 1, 2017. Magellan currently administers behavioral health benefits for Medicaid members through HealthChoices contracts with Bucks, Delaware, Lehigh, Montgomery and Northampton counties.
Magellan has over two decades of experience managing behavioral health benefits for HealthChoices members through close collaboration with members, providers and community organizations. Through this collaborative mindset, Magellan has succeeded in producing innovative efforts in the following areas:
increases in access to care
improved service use rates
expansion of the continuum of services in alignment with evidence-based models
A Strengths-Based Approach: How High Fidelity Wraparound Changed a Foster Family’s Path
|
Being a parent is one of the most challenging and rewarding jobs an individual can hold. When behavioral health challenges are added, it becomes even more difficult. Try, for a moment, to imagine being a foster parent to a child with behavioral health challenges. Where does one even begin to find the help and services they need to best care for their child?
Through our collaboration with the Wyoming Department of Health, Division of Healthcare Financing (Medicaid), Magellan in Wyoming coordinates care, including behavioral health interventions with other youth serving agencies in our system, using the High Fidelity Wraparound (HFWA) model to build a team of support for the successful management of complex conditions and behaviors in home- and community- based settings. The team creates steps to help youth stay in their homes, schools and communities. Through the 10 guiding principles of the program, families and youth have a voice in their care and choice in the kind of care they receive. We help to strengthen community support, understanding, and education of at risk youth ages 4-20 with complex behavioral health needs.
Magellan in Wyoming recently had the opportunity to hear from a former foster parent and HFWA graduate to discuss how the program benefited them through their challenges and supported their growth. “Opening my heart up to love and attachment with these children, parenting them with unconditional love, all the while knowing, they might not stay was difficult,” said the foster parent.
The siblings involved and their foster family cycled through numerous foster care workers in three years, creating more trauma for everyone. There was no stability and no consistency. Dealing with several different mental health diagnoses and many weekly appointments, in addition to the strain of everyday life, took a toll.
When this family discovered HFWA, they were naturally a little skeptical. They had experienced enough “new” things; however, this was the beginning of a completely new outlook on life. From the very start, HFWA taught the foster parent that it was okay to take a breath, to sleep and to ask for support. More importantly, it became evident that people wanted to help and be on the family’s team to help support them.
The family had spent so much time triaging the risk aspects of their children’s lives, that it had drained them of most of their hope. Through the strengths-based principles of the HFWA program, the family was able to gain new insight into ways they could focus on the local supports available to help them.
The program taught them to see the progress. By forming a HFWA team around the foster children and the whole family, they were able to gain some positive, strengths-based perspective along with stability and consistency.
HFWA empowered the family to have a voice and to use it effectively. “I knew all the people on my team before HFWA, but the program taught me how to use my voice. It taught me how to say what was going on and who to say it to,” said the foster parent. It was because of the family’s team, as well as community investment in the program, that today, the family is enjoying a life full of hope and possibility.
Helping Members Change Their Lives (And Our Own Lives, Too)
|
As a former Medicaid recipient who relied on treatment from community behavioral health centers, I know first-hand the transformative power a peer specialist can have a in a person’s life.
In my late teens and early twenties, I bounced from state hospitals to crisis stabilization units desperate to end my life. I had no hope that the goals I had envisioned prior to these struggles could be realized. When I started working with a peer specialist, I began to view myself and my future in a more positive light. My peer specialist expected me to recover and connected me to the resources and supports that empowered my recovery process. The painful experiences of my past paired with skills and knowledge of the healthcare system have provided me a platform for me to help others while creating lasting change. The opportunity to do such meaningful, passion-filled work for more than 40 hours of my week keeps me inspired and grateful to be a part of helping our members’ lead healthy and vibrant lives.
The work we do through Magellan Complete Care of Florida’s peer navigation program is literally changing the trajectory of peoples’ lives. Peer support offers hope to the hopeless. It helps our members see new possibility in a life that feels limited. I often tell the team that they have the hardest job in healthcare, as the members we support have multiple chronic health conditions, may live in poverty, and have challenges getting their basic needs met, such as food and housing. The team is 100 percent field-based and every day they show up and not only listen and support our members, but are willing to share pieces of their own story to inspire hope and change. The results have been nothing less than extraordinary. We’ve seen decreased inpatient days and a reduction in healthcare spending, but more importantly, members are re-engaging in their community and reaching goals related to their health and wellness. We bear witness to life change as members discover their power and break through barriers to accomplish what had once been buried dreams.
These potentially life changing interactions happen every single day with our staff and the members they touch. There are a lot of examples of member success stories, but here are two that underscore the power of peer support:
Kevin’s low self-esteem led him to live a very unhappy and socially reclusive life. Driven by fear of the world and feelings of being uncared for, Kevin attempted suicide. Thanks to the support provided by Magellan Complete Care through a peer specialist that visits him weekly, Kevin now lives a positive and socially involved life. He enjoys spending time with his new friends and communicating with his peer specialist.
Joe struggled with debilitating challenges such as depression, suicidal attempts, chronic homelessness, wheelchair-boundedness, severe eye health problems, frequent hospital admissions, inconsistent medication usage and medical follow-ups. Magellan Complete Care worked with Joe to move toward the road to recovery through a complex case management program with a care coordination team and a peer support specialist. The team linked Joe to medical and psychiatric providers, a mental health agency and helped him obtain an independent living facility, food stamps, a new wheelchair, phone, eye glasses, and transportation assistance to attend appointments and follow-ups. Magellan Complete Care also assisted Joe in obtaining a referral for a prosthetic leg. Magellan then linked Joe with a job agency to support his goal of acquiring a job.
The members’ feelings of hope, pride, and self-confidence are contagious and we share these feelings when we reflect on the difference the health plan and staff makes in members lives. Our members are changing their own lives, but ours are changing along with them.
Care alongside Care: Treating Comorbid Medical and Behavioral Conditions
|
It’s 11:30 on a Tuesday night in the emergency department of a local county hospital. The doctor pulls back the curtain on his next patient and frowns. He has seen this man before. He looks down at the chart and recognizes the name. He’d been in about eight weeks before with trouble breathing and chest pains. Gears click in doctor’s memory, as he recalls this patient. His medical work-up had shown nothing acutely wrong. He’d been encouraged to take his usual medications, and sent home with instructions to see his regular doctor as soon as possible to make sure his chronic diabetes and congestive heart failure were under good control.
The doctor pulls a stool across the floor and sits down bedside.
“Hi Brian, what seems to be the trouble?”
“My chest. I couldn’t breathe. And I can’t seem to concentrate. I just don’t want to do anything.” Brian’s voice is listless and low, and he looks fatigued.
“I see you were in a couple of months ago. Did you go and see your regular physician?”
Brian shrugs but doesn’t say anything. His eyes are fixed firmly on the floor.
The doctor pauses. He looks at Brian for a while. The man looks like he hasn’t taken care of himself. His clothes are wrinkled, and he’s lost some weight since his last visit to the emergency department. The doctor looks over Brian’s vitals and labs. He finds nothing concerning on physical exam. He asks, “Brian, has anyone ever talked to you about depression?”
In the case above, Brian is a fictional character, but the situation is not. The co-occurrence of mental health disorders with physical ailments is common. A Substance Abuse and Mental Health Services Administration (SAMHSA) report found that 68 percent of adults with mental disorders have medical conditions, and 29 percent of adults with medical conditions have mental disorders. The most common of these is depression. Many research studies have found high rates of comorbid depression with chronic and terminal medical conditions. In many cases, the medical conditions or treatments for the conditions can cause depression. In others, the depression itself can lead to health behaviors that cause or worsen medical illness, and even higher risk of death. For instance, persons with depression have higher rates of smoking cigarettes than the general public. This can lead to heart disease. But, depression itself can also cause changes in brain chemistry and platelets, which can worsen existing heart disease.
Common Conditions with Comorbid Depression
Comorbid depression in some medical conditions is common. According to the National Institute of Health, there is a close relationship between depression and other physical ailments:
Alzheimer’s disease and other dementias
Cancer
Coronary artery disease
Congestive heart failure
Diabetes
Epilepsy
HIV/AIDS
Multiple sclerosis
Parkinson’s disease
Rheumatoid arthritis
Stroke
Systemic lupus erythematosus
Depression also has a negative effect on treatment and outcomes for these diseases. A 2015 published research study showed those with comorbid depression had more negative outcomes for their primary ailment than those who only had the primary ailment. Research also shows a lower quality of life, lower compliance with medical treatments, and lower rates of exercise and healthy eating habits for patients with comorbid depression compared to those with the same physical ailment(s) who did not suffer from depression.
This comorbidity has consequences beyond the health of the patient. People with multiple medical conditions are a rapidly growing and extremely costly segment of the US population. Patients with behavioral health disorders spend more on treatment for general medical conditions. When compared to those without depression, overall health care spending for medical conditions is higher than those without, in addition to treatment for the depression itself.
Improving Care for Comorbid Behavioral Health Conditions
The first step is identifying patients with comorbid behavioral health conditions before they reach the dangerous and costly levels discussed above. The primary care setting may be the best place to first find depression. But how?
Magellan’s Screen and Engage program is an innovative, user-friendly application that primary care physicians (PCPs) can use to identify patients at risk for a mental illness. Using a Magellan-provided iPad, the patient answers questions about his or her health and well-being while waiting for an appointment. The screening tools are also available in Magellan’s Virtual Care Solutions. Magellan’s proprietary algorithms assess the results, identify potential behavioral health issues and suggest recommendations for treatment, and flag clinicians to engage the patients.
The benefits of the tool are clear. Given the limited amount of time that a PCP has for each appointment, he or she must focus the conversation on the primary reason for the visit. As such, there is little opportunity to probe for behavioral health concerns. By conducting the screening before the short appointment, the PCP has a chance to be notified of the screening results, and discuss them during the visit.
Screening for behavioral health conditions is just the first step. Step two is treating them. In general, depression is treated with either medications and/or cognitive behavioral (CBT) psychotherapy. CBT is a specific type of therapy that relies on identifying and changing ones thoughts that can lead to depression. Research shows that the combination of the two is better than either done separately. While it may be easy to receive anti-depressants from medical doctors, it is often difficult to find CBT.
Cobalt, Magellan’s computerized Cognitive Behavioral Therapy (CCBT) program, is a cost-effective solution to address common behavioral health conditions. Cobalt provides CCBT online or through a smartphone/tablet app. This makes face-to-face CBT—proven to work but often difficult to find providers, especially in rural areas and for working people—available anywhere, any time. It is also a more private approach to CBT. Patients can access treatment from their homes versus an office.
Computerized CBT has proven to be just as effective as in-person CBT. Magellan offers Cobalt modules for insomnia, depression, anxiety, substance use disorder and obsessive-compulsive disorder, treating more than 90 percent of behavioral health conditions seen in primary care and behavioral settings.
Tackling Comorbid Conditions for a Healthy Future
At Magellan, we have made it our mission to help individuals like Brian, whose case is all too common. Tackling comorbid behavioral health issues alongside common medical conditions is one way we do it. Investing in and using new technology, we can identify more people who need help and expand their access to effective, proven treatments.
Magellan’s Role on the National Quality Forum’s Medicaid Innovation Accelerator Project Coordinating Committee
|
When I was selected to join the National Quality Forum’s Medicaid Innovation Accelerator Project Coordinating Committee, I thought about the background and experiences I would bring with me – both personally and professionally. As a trained pediatrician, my medical training focused largely on the care and treatment of young children. According to the Centers for Medicare & Medicaid Services (CMS), more than 45.2 million children were “ever-enrolled”1 in Medicaid and the Children’s Health Insurance Program (CHIP) during fiscal year 2015. In addition, in the time since I was in practice, I’ve worked for several national healthcare companies, with a focus on population health, clinical delivery systems delivery and improvement.
Since joining Magellan as the company’s chief medical officer, I’ve worked with my colleagues to help continually looks for ways to reinvent how care is delivered. I am passionate about supporting the volume-to-value payment transformation, and Magellan has a key role to play because of the deep expertise we bring in behavioral health. Oftentimes, we don’t realize how specialized and important that expertise is, and how it impacts the overall quality of care for a patient, particularly with comorbid conditions. Magellan is also considered a trusted partner because we are an independent company and not part of a big health plan. In addition, we also bring a breadth of experience in medical specialty, medical pharmacy and long-term services and supports (LTSS) which is not found in most other organizations.
Improving Care for Medicaid Beneficiaries with Complex Care Needs and High Costs (BCN)
Promoting Community Integration – Community-Based Long-Term Services and Supports (CI-LTSS)
Supporting Physical and Mental Health Integration (PMH)
The challenges – and opportunities – are many. Medicaid behavioral health does not currently have standard benefit packages from state-to-state, and there are also not standard billing practices. Both of those elements make it much harder to develop metrics which are reliable, and more technical expertise is needed to ensure that the metrics selected can be broadly used. Ultimately, this committee will provide guidance on performance measures for areas which are unique to Medicaid, including patients with complex health needs, LTSS needs and those with behavioral health and substance use/opioid disorders. The states will then have a list of standardized measures for use in Medicaid performance program evaluation.
All of the committee’s meetings are open to the public. The IAP will issue its draft report in July, and its final report at the end of September. I look forward to working with my committee colleagues as we work to draft these important metrics related to state’s efforts regarding payment and delivery system reforms.
1These enrollment data are unduplicated counts of children who were enrolled in Medicaid and CHIP at any point in FFY 2015. A child who was enrolled in more than one program (e.g., Separate CHIP and Medicaid) at different times during the FFY is only counted in the program in which he or she was last enrolled.
What is HEDIS and What Does it Mean to You?
|
Magellan’s collection of HEDIS (Healthcare Effectiveness Data and Information Set) quality measures for 2017 has entered the final phase of data collection. You’ve probably heard of the acronym HEDIS – but what does it stand for and what does it mean to you? The Healthcare Effectiveness Data and Information Set – HEDIS — was created by the National Committee for Quality Assurance (NCQA) to measure the clinical quality performance of health plans. This is accomplished through the collection and analysis of data documenting the clinical care received by individual plan members from providers, influenced through activities and programs delivered by the health plans. The data is aggregated and reported collectively to reflect the ‘collective’ or population-based care received by the plan’s membership. These reports have become a major component of quality rating systems that measure the clinical quality performance of health plans by Centers for Medicare & Medicaid Services, states offering Medicaid and other entities. Right now, Magellan has entered the final phase of data collection for HEDIS quality measures for 2017.
There are 91 HEDIS 2017 measures, but it’s important to note that the number may vary from year to year as new measures are added to the set and some are retired. The measures cover many aspects of healthcare including preventive care such as screening tests (e.g., mammograms) and immunizations, management of physical and mental health conditions, access and availability of care, patient experience, utilization and relative resource use. Data is reported individually for each product and line of business
Measure data is collected is a variety of ways. Claims are the major source of data, but specific measures may also allow plans to survey members or to access member medical records for additional data not captured in claims. This type of data collection (combined claims and chart data) is called hybrid. The final phase of data collection for health plans choosing to do hybrid runs from January through May and is often called MRR for medical record retrieval, or simply ‘chart chase.’ Final HEDIS data covering services rendered in 2016 and prior will be submitted to NCQA by June 15, 2017. Final health plan ratings for all lines of business are published on the NCQA website by October 2017.
For health plans, HEDIS ratings can be very important. The scores on measures can help them understand quality of care being delivered to their members in some of the most common chronic and acute illnesses. Higher scores can help compete more effectively in various markets. HEDIS score reporting are often required in public markets as well, where the results are often reported to the states, or occasionally counties, in which the plans reside.
Behavioral health and pharmacy are well represented in the HEDIS measure set. Behavioral health has multiple measures that include ensuring continuity of care, appropriate psychotropic medication management/adherence, and initiation and engagement of drug and alcohol abuse treatment. Pharmacy measures focus on medication management of acute and chronic physical and mental illness, appropriate medications in the elderly, and management of polypharmacy. Specialty measures are directed toward inappropriate imaging.
So, what is the value of HEDIS to Magellan? Aside from being a collection and reporting contract requirement for many of our customers and our own health plan, HEDIS gives Magellan valuable information about the populations we serve.
By following the behavioral health data, we collect, for example, we can identify gaps in network performance in patient follow-up patterns, management of drug and alcohol abuse, and prescribing and adherence to medications. This allows us to design and implement interventions that can improve outcomes and reduce cost of care.
The same type of analysis/intervention applies to physical health conditions. Analysis of HEDIS data helps identify gaps in care, particularly preventive care, in such important and chronic populations as patients with diabetes mellitus, patients with cardiovascular disease, and patients with lung disease. We can also identify and address at-risk pediatric populations who fail to complete preventive care such as immunizations, dental and well-child care.
As the healthcare industry moves more and more toward value-based purchasing, all providers, insurers and their vendors are necessarily increasingly focused on the quality of care that is delivered. The impact of this should be better outcomes for our members.
Developmental Disabilities Awareness Month and the Importance of Self-Direction
|
Thirty years ago, President Ronald Reagan deemed March to be Developmental Disabilities Awareness Month. Awareness months are an important advocacy tool, as they provide opportunities to reflect on progress and continue meaningful conversations about the future. For many people with developmental disabilities, ensuring these discussions take place can be the difference between being invisible and living as full citizens in their communities.
Developmental disabilities awareness is something near and dear to me, not only as the president of TMG by Magellan Health—supporting the largest self-directed long-term services and supports program of its kind in the country—but also because of my graduate work. During my practicum, I worked on the South side of Chicago, assisting low-income families who had children with developmental disabilities. Too often, these families, many of them single mothers, struggled to find the necessary services to help their children live as independently and inclusively as possible. The isolation the children experienced was heartbreaking.
Fortunately, in the 20 years since then, I’ve seen wonderful strides in the resources available for people with developmental disabilities, as well as greater expectations for community inclusion. Self-direction has played a crucial role in this progress. With self-direction, individuals choose not only the services they receive and who provides them, but also how they live their lives. This means people have control over things many of us take for granted: living where and with whom we want; making our own schedule; having meaningful, lasting relationships; pursuing our hobbies and passions; and finding meaningful work or volunteer opportunities. There’s been an amazing nationwide movement towards self-direction, which is not only a best practice, but also the cornerstone of TMG’s work in Wisconsin’s innovative IRIS (Include, Respect, I Self-Direct) program.
While there’s been great progress in raising expectations and increasing opportunities and resources for individuals with developmental disabilities, there’s still much to overcome on the path towards greater acceptance and inclusion. Thankfully, as community inclusion and self-direction are becoming more commonplace, society increasingly recognizes the contributions that people with developmental disabilities can make. As a leader in helping individuals create healthy, vibrant lives, Magellan Health is at the forefront of self-direction with its Wisconsin program, and is building a strong self-direction component in its new managed long-term services and supports (MLTSS) program, Magellan Complete Care of Virginia.
So as you make your way through March, take time to think about the people in your life and in your community and how we can all support one another. Learn how to be a better advocate for individuals with disabilities at sites such as ACL.gov and NACDD.org, and read stories of self-direction in TMG’s The Path Ahead. Encourage and support inclusion and independence whenever you can. But mostly, take the time to get to know people for who they are and appreciate their individual gifts and talents.
Managing Transformation Across Healthcare: Key Highlights from MOVE 2017
|
In late January, Magellan held its second annual Magellan Open Vision Exchange (MOVE) conference in Scottsdale, Ariz. MOVE brings together a large cast of voices from the healthcare industry to discuss the future of healthcare for patients, plans and providers. Over two days, we heard from private industry experts, government leaders, as well as other subject matter experts and thought leaders both from inside and outside the healthcare industry.
The Future of Healthcare Beyond the Affordable Care Act
Obviously, the continuing debate over the future of healthcare and the Affordable Care Act were a central topic of the conversation at this year’s MOVE. A number of speakers talked about the impact of the Trump Administration’s efforts to repeal the Affordable Care Act. Former Utah Governor Michael Leavitt, who also served as the secretary of the Department of Health and Human Services, said that while he expects repeal and replace legislation will pass, significant parts will be deferred for three or four years. Brian Coyne, VP of federal affairs at Magellan Health, said that he feared gridlock over the next couple of years.
Managing Transformation in the Healthcare World
One of the key topics discussed at this year’s event was the immediate future of the healthcare industry. After a long period of explosive innovation, there was consensus that disruptive change will continue. Magellan Healthcare CEO Sam Srivastava posited that we are currently in a tech-bubble that is about to burst. The industry is waiting to see which of the early healthcare technology entrants will survive and how technology and healthcare will continue to interface with each other.
Leavitt spoke extensively of the need to manage transformation, especially in healthcare. Leavitt stressed that systematic healthcare change takes hold over three to four decade cycle, and he believes we are less than mid-way through the current transformation. Using an analogy of a cattle herd, Leavitt made the point that you can’t drive a herd too quickly, or you risk a stampede. You also can’t push the herd too slowly or it will meander. Applied to healthcare, the idea is simple but true: If we push change too quickly there will be chaos, but if we fail to adapt and change, we will stagnate. Allowing ourselves to be “lulled into inaction” is a recipe for disaster.
Value-Based Healthcare
A critical area of discussion was the expansion of value-based care. Speakers agreed that demand for value-based care is accelerating. Leavitt said he believed this was true regardless of the Trump Administration’s plans for healthcare. Billy Millwee, President and CEO of BM&A Public Policy, cited broad bipartisan support for the value-based model and agreed that it was here to stay.
Chet Burrell, president and CEO of CareFirst BlueCross BlueShield, spoke clearly on the approach that his company was taking: “We started and ended with common sense.” He went on to explain that they had built their model with the primary care physician at the center (PCP). The PCP knows the patient best and is therefore in the best position to make decisions regarding who to refer and to whom. By taking this approach, Burrell relayed, CareFirst was able to build a patient centered medical home model that improved care while reducing costs.
Despite the level of change being experienced throughout healthcare, a common theme was one of our industry being grounded in helping people get the high-quality care they need, affordably. This is the essence of why healthcare is our chosen industry and why we are driven to innovate.
An interesting takeaway was that across the conference and speakers, there was a clear common theme: while the ultimate structure of the pay-for-value transformation is uncertain, the movement will continue. Experimentation, promoted by both public and private payer initiatives, will drive innovation and change. Some will be better prepared than others to handle this paradigm shift.