The Mental Health and Mental Retardation Authority of Harris County

A number of forces are at work as Fiscal Year 2003 approaches – pulling, pushing, and swirling with increased intensity. The result will/may be (depending on whether certain factors come to fruition) a system of care that will significantly differ from what has been in the past. On the one hand, it may very well be more responsive, consumer focused, and better defined. On the other, it may be much less flexible, more “fundor” driven, and more “managed” (in the managed care sense). Let me explain:

The public mental health “safety net” is going through a major, gut-wrenching retrofit from clinical resources to financing. Grant programs are being “retooled” to live within the funding provided by the primary payor. In those areas where state tax dollar general revenue (GR) was being used to address grant deficiencies, that GR is being pulled out and the grant funding expected to carry the service package. In those areas where the consumers have third party insurance, the insurance payments are increasingly expected to cover the costs of the provider system delivering that service. Where there is compelling justification as to why GR is needed to supplement the third party coverage, it is being maintained as a part of the method of finance for that provider component. If not, the GR is being reduced and the expectations for third party earnings increased to ensure a balanced budget.

A process is under way to ensure that the GR available (albeit woefully limited to meet the needs of the vast numbers of people who need and seek safety net services/supports from MHMRA) will be clearly utilized in ways consistent with the directive of TDMHMR through its annual Performance Contract – following the direction of the Texas Legislature. So, when the Legislature reduces the GR for Child/Adolescent Mental Health Services (CAS) with the expectation that CHIP revenue will rise to make up the loss, the GR goes away in FY03 and the expectation is that the services of the CAS division will rely increasingly on its earned revenues. The high percentage of CAS consumers with third party coverage (primarily Medicaid, not CHIP) must be followed by a much more commensurate level of real earnings collected through the third party sources. Expectations have increased to deliver appropriate, needed, and authorized services – tied to the child’s coverage and condition – and, most importantly, to bill and collect the funds that should support this care. The GR will be refocused to address TDMHMR expected “gate” and oversight functions along with the care needed and justified for children who are uninsured or underinsured. Each aspect of the service system has to be scrutinized and “trued up” to function in an efficient and appropriate fashion. Where there are barriers, inefficiencies, increased costs, and/or constrained productivity, they must be reduced and, to the degree possible, eliminated. For example, several facilities are being closed which consolidates staff and reduces the cost of operations. By using other Agency sites, accessibility for consumers/family should not be substantially impacted. In addition, co-locating with other community organizations (i.e., several school districts) will further ensure that clinical staff resources are doing what they can and should be doing – delivering services – in locations more readily accessible for the children. The support components have been and will continue to strengthen the documentation, billing, and collection aspects of the system to close the loop -- to provide the needed care, bill for that care, and collect the reimbursements. What is also expected as a clear objective of this process is to better identify and focus the GR resources to deliver the services in ways consistent with the intent and direction of TDMHMR which is primarily to support the care of the uninsured and match those third party services, where appropriate.

The Adult Mental Health division (AMH) is going through a similar, if not, more painful re-engineering process. For FY03 there is simply not enough GR to support the “provider system” as it is currently configured. Major changes involve reshaping the AMH clinic organizational, administrative, and provider resources. The medication services provided by the doctors, nurses, pharmacists, and LPHAs are being reconfigured into a clearly defined physician practice model with performance expectations identified and implemented. The rehab, counseling, service coordination, supported employment, and supported housing resources are being re-aligned to better ensure that services are provided at a level of productivity consistent with clinical justification and payor coverage authorization/capacity. Tailoring the right services in the correct amounts over the justifiable time periods consistent with the package of benefits for each consumer – tied to his/her diagnosis and severity level -- is where we are going.

And going none too soon, TDMHMR will pilot this next fiscal year the initial case rate methodology for the anticipated revised benefit plan to be utilized within the TDMHMR consumer network, perhaps as early as FY04. That plan is expected to marry the “evidenced based” services for each consumer by diagnosis and severity with funding to provide those services through one of currently proposed four case rates. As the consumer’s condition meets criteria for a higher level of funding with an expanded package and intensity of care, the rate would change, funding increase, along with the expectation of intensified care “wrapping around” the individual. The converse would also be true for more stable, responsive conditions. The ability for the local system to utilize the GR dollars in flexible, perhaps more community focused ways, may dramatically change. But the funding and services in the near future will be more justifiably tied to the severity of the person’s condition.

Which leads to the potential for such a “constriction” in service system responsivity this next fiscal year within the Mental Retardation division (MR). Texas leadership is pursuing an Essential Services Waiver as an option for further cost sharing with the Federal Medical program for existing consumers. If implemented, this is expected to free up GR that is currently in use providing the care for those consumers in the system and address a portion of the Promoting Independence waiting list needs. What does this mean? Well, the current system provides GR to the community MHMR system, a quarter in advance to address local service/support needs not covered under the Medicaid (HCS and ICF-MR) program. The GR enables the local center to design and implement services and supports tied to local MR priority population resident needs not covered through the Medicaid program but covered under the annual Performance Contract with TDMHMR. By creating a new Medicaid waiver program (a services “lite” program) the services/supports for those individuals who are Medicaid eligible would be covered under the waiver at a shared cost with Medicaid (approximately 60% federal Medicaid and 40% GR match). We are advised that some GR funds will be retained in our system to be able to continue serving those persons who are not Medicaid eligible. The “freed up” GR (the 60% then covered by Medicaid reimbursements) would be pulled back to match additional HCS slots under Promoting Independence, thereby addressing many people waiting for these more intensive, wrap-around services, and, potentially, substantially reducing the existing waiting list. Such a waiver may, indeed, move people from the waiting list into services. And, through the Medicaid program, current consumers will have increased provider choices available. What may also happen, as an unintended consequence, is to move the MR division almost entirely into a fee-for-service model, reducing the cash flow that has been available to the system in the past and place ever increasing pressure on the adequacy of the infrastructure to bill delivered services and collect on those bills in a timely fashion such that the resources are present to cover expenses as they are incurred. Such a model may (that is the operative word – contingent on how much existing service/consumer care is wrapped up into the waiver) also have the unintended consequence of reducing the Agency’s ability to use a portion of the GR dollars currently available to address community needs through innovative options.

What should not be expected through all of this is that the system will be “fixed”. By that I mean we may have a better fit of what resources are available to address the clinical needs of the covered consumers. It should see a closer correspondence between the nature and severity of each person’s condition, the resources available to address the services and supports justified, and the choice of the consumers in selecting the “best” provider(s). These changes may create some potential expansion of the services and supports available and better align the GR dollars, coupled with third party earned revenues, to more closely mesh needs with receipt of services which are clinically justifiable as long as the payor authorizes such care. It should not be expected to “fix” the ripple effect of a continuing under funded public mental health and mental retardation system. It should not be expected to vastly expand the number of consumers who get access to the “safety net” services/supports that are needed and warranted. We will still be rationing care – but doing a better job in a more rational, objective fashion.