So good morning everybody. We wanted to welcome you to today's webinar on financing team-based coordinated services. I am Judith Doberman, the program manager for PetNet at Stanford University School of Medicine. And with us today is Dr. Kate Hardy, who is a clinical psychologist and a clinical associate professor in psychiatry and behavioral sciences in the Stanford School of Medicine. And also joining us today is Dr. Steven Adelsheim, who is a clinical professor at the Stanford Department of Psychiatry and Behavioral Sciences, the associate chair for community partnerships, and the director of the Stanford Center for Youth Mental Health and Well-Being. And both Drs. Hardy and Adelsheim will be co-facilitating with our presenters today your questions. So today's webinar is brought to you by SMI Advisor. And SMI Advisor is a clinical support system for serious mental illness, and it's a substance abuse and mental health service administration funded initiative implemented by the American Psychiatric Association. And now to introduce today's presenters, David Shearn, Dr. Shearn has served as the president and CEO of Mental Health America, formerly the National Mental Health Association, and on an interim basis in 2014. After leaving Mental Health America, Dr. Shearn joined the staff of the National Association of State Mental Health Program Directors as a senior public health advisor. He also has an appointment in the Department of Mental Health at Johns Hopkins. Dr. Douglas Robbins is with us today, and he has been on the faculty of the Department of Psychiatry at the University of Michigan at Brown University, at Maine Medical Center since 1996, and the University of Vermont and Tufts University. Dr. Robbins has led inpatient, day treatment, and outpatient programs. His continuing focus has been on early identification and treatment in children, adolescents, and young adults of early stages of serious mental illness. And now I turn the webinar over to our presenters. Thank you. Okay. David, you want to go through the learning objectives? Sure. We're going to, at the end of this webinar, you'll be able to describe cost challenges associated with implementing evidence-based treatment, discuss domains and dimensions of cost-effectiveness in early treatment of psychotic disorders, summarize limitations of the current fee-for-service funding stream, and explain payment models that can be used to cover the costs of CSC, Coordinated Specialty Care Services, for persons with first episode psychosis. Many of the learnings are generic to any sort of bundled and team-based service. Can we go to the next slide? There we go. I thought we'd start with just the, what is the problem we're dealing with? And I think all of us are familiar with the fact that psychotic disorders are, in many cases, really very devastating. And they can incorporate different underlying diagnoses. We tend to think first of schizophrenia. They also include the affective disorders of psychosis, bipolar, and major depressive disorder. In some cases, often substance OCD. The studies in this have tended not to include those who have substance abuse-based psychosis, sometimes other psychotic disorders may be precipitated or exacerbated by substance abuse. The overriding reality is that the outcome for all of these disorders is very poor. It's somewhat variable among the diagnoses, but it's very poor with impairment of quality of life, serious impairment of people's ability to hold a job, maintain family relationships. They use a lot of high-end expensive services and subsequently incur a lot of costs. And then there are other societal costs with corrections, disability-related welfare, and education costs. It's also very clear now that the people with these disorders die early. In many studies, it's as much as 25 years earlier mortality. This has to do with both cardiovascular illness, also, to some extent, being victims of violence and also suicide. And it's important to know that this is increased mortality and morbidity, independent of the medications that we put them on, which tend to make things worse. So go ahead, please. Next slide. Next slide. Yeah, thank you. So the good news is that there is an effective approach to treatment that the... And this has been referred to in the United States as coordinated specialty care. There are models of this that are very similar that have been tried, implemented, and tested around the world. Quite a bit of study in Europe, Denmark, particularly. It's a wonderful team. And all of these converge in this group of interventions. And one of the main take-home messages is that this is not all pharmacotherapy. With these diagnoses, people tend to think of medications, hospitalization, and discharge without a lot of focus as often. Not inevitably, but not as much focus as we might like on the rest of the psychosocial treatment package. So the common denominators of what works are a team-based approach, as opposed to fragmented care with services being done around the community, to case management, care coordination, supported employment and education, recovery-based psychotherapy, and particularly in psychotic disorders, cognitive behavioral therapy for psychosis, of which Dr. Hardy is an expert, family support and education, and evidence-based pharmacotherapy in coordination with primary care. And the pharmacotherapy is a delicate balance between trying to be very careful to engage patients and not give them an aversive experience because of negative effects of medication. So it's part of the strategy of engagement. And more recently now, programs are very commonly including peer support. And these are young people who themselves have experienced these or other mental illnesses and have some perspective and are able to guide others. So next slide, please. Now, and when these programs are implemented, there are a number of outcomes that are quite positive, that are quite consistent across studies. And I refer up there in the heading to Dr. Cain and Dr. John Cain, Lisa Dixon, who headed the RAYS studies, that stands for the Recovery After an Initial Schizophrenia Episode, in the United States. Dr. Asitano and McCrone and others at the University of London in the UK, King's College, London. Vinod Srihari has done a randomized controlled trial in Connecticut. In all of these, you see a wide range of improved outcomes. People are able to remain in school and in employment or to return to school or employment. You see a significant decrease in the need for hospitalization. And this is in contrast to high rates of rehospitalization after a first episode of psychosis in usual care. Overall improved quality of life. And to the extent different studies have looked at this, you see decreased suicide risk. And this is very important because the suicide risk in the first year after a psychotic episode is extremely high. Like Michael Schoenbaum at the NIMH has a paper in which he cites that and refers to this very high rate of suicide, which can be diminished substantially. Improved family relationships. Instead of becoming estranged from families and often becoming homeless, that improves. We see less homelessness. I should say also, I don't have it listed here, but less involvement with law enforcement, less incarceration, decreased substance abuse, and improvement with the medical situation, morbidity, and mortality. So the bad news is these are devastating illnesses. The good news is there really is effective treatment. And I should note here that we're focusing today on first episode psychosis. That is people who have already developed overt psychotic illness. A huge body of work that Dr. Adelsheim and others know very, very well involves trying to intervene when people are at a state of high risk or so-called clinical high risk for psychosis prior to having overt full symptomatic symptoms of psychosis, but more likely sub-threshold symptoms or symptoms with familial risk. And in that population too, there's a wonderful review by Dr. Fusar Poli, shows you also see some of these same positive outcomes. So next slide. Cost effectiveness and assessing cost is really what we want to focus on today. And I should say that the reason we focused on this is that in common with the challenge of implementation of evidence-based practices throughout mental health, or actually really throughout medicine, you encounter the fact that many of the procedures and steps and components of treatment are not covered by the formulas for insurance coverage, which are often based on the data from a couple of decades ago. And so starting such a program encounters a barrier that it's in many cases not supported financially. And they spread throughout the country in the United States, largely through federal support, through SAMHSA and support from the NIMH, and particularly with SAMHSA's community mental health block grants and the so-called set aside for serious mental illness. So that's been overall quite successful in spreading these programs, but it only goes so far to make the access really be what it needs to be to have the reach to get to patients who really need this. This needs to be woven into the health insurance system, which it clearly is not. And it's a problem both with Medicaid insurance and also with commercial insurance. And costs occur in many different areas or domains. What we generally mostly talk about is the cost of treatment itself. So what we call direct treatment costs. What we often have more trouble tallying up are the costs to families and caregivers. They pay a considerable amount of amount out of pocket with co-pays and limits on their coverage, high deductible policies, and so on. They also incur costs around time off from work or having to cut back from full-time work. So the family's income is often cut at the same time that they have new costs. Then there are other areas of cost to society that aren't directly related to health care. The lost productivity to the economy as a whole, law enforcement, disability, homelessness, and educational accommodations, and then other medical costs. So this is expensive in many different areas, and we have an effective treatment, and yet it typically is not well paid for. So our point here, one of our points is we really want to underscore that there are studies that show that this is in fact cost effective, and it makes good sense, good business sense, for coverage of this to be part of the insurance fabric. Next slide, please. In the different parts of the program that were on the previous slide, there are a number of components which are rarely, if ever, covered by insurance. You know, some things are, like psychotherapy sessions, medication management sessions, those are paid for, sometimes not sufficiently, but they are paid for, and sometimes not sufficiently because you may have to be working more intensively with more frequent sessions than are customarily covered. But what's most frequently not covered are the outreach and engagement work that needs to be done to bring people into treatment. Because, you know, business as usual, treatment as usual, often after an initial episode, includes a degree of denial. The young person is not, understandably, and maybe parents too, not eager to conclude that they have a serious long-standing illness, ongoing illness. So they may attribute it to a relationship issue or a transient substance abuse issue. So engaging people in ongoing treatment is often a challenge. It involves then having to get out to the community and referral sources, such as primary care and schools, so that they'll know what to look for, how to recognize these patients, and that's both at the, and this all applies to the at-risk, high-risk population who are not yet psychotic, but who are at risk for it. But you have to do a lot of community education. When you do this, you find that the, that people come into treatment earlier, and the, what's called the duration of untreated psychosis, the period of time that people are seriously ill, which is a high predictor of poor outcome, comes down substantially. And you start getting people engaged in treatment earlier, and subsequently, simply related to the early treatment, you have better outcomes. One of the well-known models of this is a program in Norway called TIPS, T-I-P-S, which did a very substantial community education process, which clearly decreased that duration of untreated illness markedly. What was notable was that when funding, grants ran out, or funding shifted, and that stopped, the delay in getting people into treatment rapidly drifted back up to what it had been before. So this has to be an ongoing effort. It's not that you just do one series of workshops or presentations, and you're done. The supported education and employment, this is virtually never paid for by insurance, Medicaid, or commercial insurance, except in very unusual situations, perhaps related to a specific defined disability. And the peer support is generally not funded. Other things are funded, but often not sufficiently. One can bill for family psychotherapy, but the reimbursement is not always what we would want it to be. We and some other programs have quite a bit of success with an approach called the Multifamily Psychoeducational Group. And that's, again, can be paid for somewhat, but not sufficiently. Team-based care is actually a cost-effective way of spending people's time, but you're not dropping a bill for the time that you're in a team meeting. And yet, by doing the team-based care, as opposed to fragmented care, and the time on the phone and in direct contact that goes into care coordination, those things really will produce much better outcomes. But they are not something you can bill for. I've mentioned the frequency of medication management, and the whole process of training. If you're going to have your staff trained in CBT for psychosis, which is very important, very effective, that means time when they're not billing for activities, they're offline, in a sense. And that needs to be part, that's part of the cost of a program. So all of these components have to be included. So next, please. Let's see. And we may have this on another slide, I was expecting this here, but there's a very good time and effort study in New York State by Tom Smith and others, that showed that at its best, you can recoup about 40% of the cost of a program through insurance. And in most cases, certainly in our own program here in Maine, we are able to recoup far less than 40%. But in terms of the cost effectiveness, this can be looked at, cost effectiveness has become a very interesting science, and we won't go into a lot of detail about that. But there are, roughly speaking, two kind of categories of cost studies. One has to do with the direct cost of services or what we might call cost effectiveness. Does the cost of the intervention and subsequent care prove to be less than the cost of usual care or greater than the cost of usual care? In other words, just what does this cost or what cost does it save? And the finding in that has been in a number of studies, that even on the short-term basis, you see a reduction in healthcare costs. And that's particularly because people in this treatment don't need to go to the hospital so much. You see the rehospitalization rate come down. And when hospitalizations happen, they're often brief because you have an outside team that knows the people, knows the clients and families very, very well. So I listed there a big review from King's College in London, Asitano and Macron, reviewing a dozen different programs around the world and finding that they clearly showed evidence of cost effectiveness. And it's notable there too, that that included programs that focused on early schizophrenia and also programs that included affective psychoses as well, which some programs do not. Vinod Srihari in Connecticut has done a randomized controlled trial with this model of care, coordinated specialty care, compared to usual care, and there too showed a net cost savings because of reduced hospitalization. You spend somewhat more on outpatient treatment than you otherwise would, but then you get a substantially greater decrease in hospitalization costs. The second category of cost effectiveness studies has to do with the idea of value, with a capital V, or is in value-based healthcare. This is a concept introduced over 10 years ago by Michael Porter at Harvard, with the idea that we're not just looking at the cost, but what is the value of a healthcare intervention. And this is not unique to mental health, this is throughout all of medicine. So this is basically, it's the improvements in the quality of life or function relative to costs. So you may have increased costs, but do you have commensurate sufficient increases in the quality of life or other outcome measures? And Rosenheck and others have done a very careful study of costs in the RAISE trials, the trials led by Drs. Dixon and Cain that I referred to earlier. And they do show that there is evidence of improved quality of life relative to cost. And so from that point of view, the indication is that the cost is worth it in that there's a resulting quality of life. Now, worth it is an interesting term because these cost assessments all involve looking at the society's, quote, willingness to pay, unquote. And for that, it's important to look at what are we paying for other kinds of healthcare. And in a slide that David's going to talk about, there's some comparisons that are interesting, but this is well within the scope of what we're commonly used to covering through insurance. This will cost you far less than chemotherapy for cancer. It will cost you less than kidney dialysis and transplant. And it's consistent with what we pay for other services. And we'll come back to this, but I think the notion of mental health parity comes into this. We have an effective treatment for a serious illness that our society is not sufficiently covering. Now, long-term studies have really not been done regarding costs, but because people are not going to the hospital, they're in some cases, many cases, continuing with employment, if not full-time, then part-time, and not incurring costs in education and special education and incarceration and so on. I think it's a reasonable hypothesis that longer-term studies are going to show even more positive effects over time. Next slide, please. David, do you want to say something about this one? Yeah, I think this is where I pick up, Doug. Thanks. You did a terrific job of teeing up all the issues around the characteristics of the programs, the difficulty in terms of funding them and our lack of ability to fund stuff effectively, really causing a diminished access to these services, certainly from a population basis. And so what we've done here, and Doug was introducing these concepts before, is just to talk about how expensive these services are. I think in mental health, we have a tendency to underestimate the value of what we provide and also to overestimate how costly it is relative to other health procedures. And I think this in part reflects the history of our programming and the marginalization of mental health services that has happened over the years. So based on data that we collected from several programs around the country, as well as information from that very careful cost study that Doug was talking about, we estimate that typically these programs cost between 12 and $1,500 per client per month. And so if you multiply that times 12, and what we did is we used the actual estimate from the RAISE study that Doug was talking about that Bob Rosenheck and colleagues did, that comes out to about $15,200 per person per year. And as he was saying, you know, if you compare that with an angioplasty, which insurance pays for without batting an eye, you can see that that costs twice as much, $32,000. A knee replacement, very commonly done. And we're certainly not saying that these procedures shouldn't be done, but that costs again about twice as much, $29,000 a hip replacement, about $32,500. Pharmacotherapies for cancer can run between 30 and $50,000. And then in a 20-TEL study that we referenced, they noted that 12 of the 13 new drugs that were approved for cancer care cost over $100,000 a year. So when we put these types of services into the context of ordinary medical care and things that we pay for, we being us cumulatively through our insurance and government programs, we're talking about a relatively inexpensive program. Next slide, please, Judah. So this is a slide around parity, and Doug also mentioned that, and essentially that was building the case for parity as we talked about the fact that as compared with other routinely provided services, these services that are evidence-based and have been shown to make a big difference in terms of at least the short to intermediate term outcomes that people experience. And as Doug suggested, our hope is that will ultimately bend the long-term curve of disability and keep people in their lives much more effectively are not routinely paid for. And from our perspective, I think we can make a compelling argument that that's unequal treatment and that the services under the parity law should be included in insurance payments. Judith, next slide. So what we wanted to do, this is a kind of a finding that cuts both ways. What we wanted to do is say, what would it cost for an insured population to add this benefit at the rate at which we're estimating it will cost? And so what we do here is we go to that Rosenheck study that we've been talking about, the cost-effectiveness study, and we look at the marginal increase in costs. So there was a marginal increase in cost for this provision of CSC services rather than usual treatment. So in other words, the additional cost of covering these services is the difference between usual treatment and the experimental treatment in the RAISE study. And then the second thing we did is we took some incidence data, some from an insured population by Simon and colleagues, looking, I believe, at the Kaiser population, and then colleagues in New York used very similar procedures to the very careful procedures that Greg Simon used to estimate the prevalence of, I'm sorry, the incidence of these illnesses in the population. We then took the population data for New York State for 2010, and all of this was done, this is what I call a back-of-the-envelope calculation. So if there are any econometricians in the audience, please bear with me, because this is really just to kind of scope things out. It's not at all, it's not terribly precise. We could see a bunch of different ways to improve it. If you look at the number of people that we expected to treat and the additional cost that would be associated for the provision of coordinated specialty care, we estimated that the additional cost to an insurance premium would be about 16 cents per member per month, assuming a two-year length of stay, which is a typical duration for CSC programs. And we know that that would be if we treated every incident case, which would be terrific, but it's a very high bar. If we treat only, if we treat 75%, which would be, I think, an enormous improvement over what we're currently doing, that drops the cost to about 12 cents per member per month, and an additional premium of about $1.44. And so I think the good news here is that luckily, given the relatively low incidence of these disorders, although both of those incident studies showed much higher incidence than we had ordinarily assumed, this is very affordable and have a very small impact in terms of the increase in premium for an insured population overall. Now, that's the good news. So this is not a budget buster. And as Doug talked about earlier, this doesn't include all of the external costs, cost to families, cost of lost productivity, et cetera, et cetera. This is just direct budgeted treatment costs. That's the good news. The bad news is that sometimes, and I think we've experienced this, and Doug may chat about this a little bit later, sometimes, because it is relatively low incidence, compared to things like depression or anxiety disorder, which we know are high prevalence and have high comorbidity with other conditions, because it is relatively small, it can be difficult to get the attention of payers. It's just not big enough on their radar to merit their attention. And we're working on that. We'll continue to work on that for all the reasons I think that everyone on the call would concur with. Judith? So what do we need to think about in terms of coming up with a strategy for funding overall? So it's clear that, and Doug mentioned the study that Tom Smith and colleagues did in New York, that we're not, even in a very richly funded fee-for-service system, like the Medicaid system in New York, we're just not gonna be able to cover these costs. And he did a great job of identifying those components of care that are just not billable, but seem to be critical to the success of the model. We have to anticipate variability among programs. So rural populations, for example, have a different set of challenges in terms of providing the kind of wraparound supports that you might have in an urban population. Density and the number of persons who will become ill, and the number that need to be served by a program, all introduce challenges. There's a variation in the duration of care. There's issues with regard to transitions in care and how we appropriately continue to support individuals as they get better. And these are all open questions and open issues that we need to continue to study and better understand. And Doug talked a lot about this and how critically important it is vis-a-vis the reduction in the duration of untreated psychosis, and that many of the components of the CSC-type models are not immediately attributable to a particular individual. Annie talked about outreach and engagement. So you might be doing engagement-related services for a person who has not yet been enrolled in the program and would not be, under most ordinary circumstances, billable. But without those engagement services, which are particularly important for young adults, the program is not gonna be as effective as it can be. And again, we'll start to see that duration of untreated psychosis creeping up. Training, ongoing training is critically important to keep the skills sharp. We have a real problem of workforce turnover in these programs for a number of reasons. We could do a whole nother webinar on issues of workforce and turnover. And continuing to have the availability of training from the purveyors of these evidence-based programs is critically important. And being an all-time program evaluator myself, data and monitoring is also an essential component that's difficult to fund. If we're gonna have a real quality improvement program, it's really important that we actually have information. And there's lots of good examples around the country of information systems that are in place that allow for that kind of monitoring. But again, it can be difficult to cover. And our proposition for you is that all of these, to have as successful a program as we would like, need to be considered in terms of what needs to be available to effectively fund the program. Judith? So what we're gonna do first is talk about, use some examples that can be used to fully fund these programs. And this is going to be, so now, so before I apologize to the econometricians in the audience, now I'm gonna apologize to all of the Medicaid experts in the audience. Because as we develop this webinar, and there's an issue brief that the SMI advisor has available, which essentially reviews most of the material at the back end of the presentation, a little less so on the front end of the presentation. We wanted to put together something that was accessible to a general audience around general strategies for funding. And anybody who knows anything about the American healthcare system knows it is not a simple system. It's a complex system with multiple rule sets and multiple and multiple constraints. But fortunately, in the Medicaid program, there are at least four strategies that can be used to fully cover the cost of coordinated specialty services. You can amend the state plan. We're gonna go into each one of these in some detail, not a lot of detail. If you have a Medicaid managed care plan in your state, you can use what's called the INLUA provision to fully cover the costs or largely cover the costs. There are of course some caveats of the coordinated specialty care. The Centers for Medicare and Medicaid Services has specifically instructed state Medicaid directors on how SMI, SED waivers can be used to fully cover the cost of coordinated specialty care. And then finally, we caught one of the errors that we didn't catch the second one. This is an embarrassment for me in that I have misnamed certified community behavioral health clinics as comprehensive community behavioral health centers. And you'll see we have a slide that features, we'll have the correct title on it. But as I was reviewing this earlier today, I missed this one. So that's my bad. But now you'd be more likely to remember it since I had an opportunity to really highlight my feebleness to the entire audience. And we're gonna talk about each one of these specifically. And then we'll return to commercial insurance and the importance of commercial insurance since so many people who are developing these conditions are young adults, many of whom, because of the Affordable Care Act are on their parents' insurance and should have access to this. And anyone covered with commercial insurance who has this illness should have access. And we'll talk about some progress that we're making on the commercial side as well. So Judith, let's talk about amending the state plan. So I think in some ways that the simplest way that one might have done this, although many states have moved into managed care, which suggests a different strategy is to amend the state plan to include these services. And this strategy is sort of a two-pronged strategy. The first is you have to have permission to provide home and community-based services, HCBS services. And this allows for the inclusion of supported education and supported employment as community-based services. So as Doug mentioned, the supported employment, supported education are some of the components that are most difficult to fund. And if you have this HCBS, home and community-based services provision, you can cover those services. Then you can request from CMS, the Centers for Medicaid and Medicare Services, that CSC be covered as an evidence-based service under the rehabilitation option. So the home and community-based services gets the employment education in there. And then many of the other services are covered in the rehabilitation option. And it's possible then to actually calculate the cost of the delivery of direct services involving case management, or many of the specific client-based services that Doug talked about earlier. You can calculate the cost of those. You can estimate the number of encounters that you're going to have for people with these programs over the course of a specific period, like a year or a month, and divide the number that you're gonna provide into the total cost. And you get a per-contact, there are several different ways you can do it, but for simplicity, let's say a per-contact reimbursement, that if you hit the number of, the volume of services you're anticipating, it'll fully cover the cost of the services. So you say, well, Dave, that's good, but that's only half of the story, because Doug made a compelling argument that other services like outreach and community education and engagement are critically part of the overall approach that's necessary. You can cover those through use of the administrative component of the Medicaid programs. In other words, these can be covered as administrative expenses. One has to establish a center of excellence that will provide the services like training, programming evaluation, oversee outreach and public education, and that can be a service energy entity itself, or it can be a separate entity. We might talk about that a little bit later, because there are several centers of excellence around the country. And the nice thing then is all of those non-client specific services can be covered through the administrative component of the Medicaid program. That's very important to understand. And I think not as well understood as it might be. So strategy one is amend the state plan. Judith, let's look at strategy two. And this is for states that have Medicaid managed care. And that, I don't have a current count at my fingertips, but that's a lot of states. It's not at all uncommon for states to be using a managed care program. And if you have Medicaid managed care, a service provider can be encouraged by the state to ask the state if they can provide coordinated specialty care as an in lieu of service, meaning that this service is in lieu of other services that could be used, would be used, and would not be available under ordinary fee for service conditions, as long as it's shown to be an evidence-based service and we can check that box. It's specifically tailored to persons with FEP. And we know that with first episode psychosis, and we know that most of the programs we're aware of have very consistent admission criteria for people who they serve, and that it can be offered in lieu of other services. That's where the in lieu of comes from. If that's the case, they can then negotiate a rate between the service provider and the managed care company, right, for the provision of these services, and that rate will be cost-based. An example of this is Pennsylvania. Pennsylvania has Medicaid managed care. And as of the last time I spoke with Jill Stempelair, two of their counties are offering bundled services cost-based reimbursement for community, for comprehensive, for CSC services using this provision. Now, given, oftentimes when you do this, you need to have an actuarial study to demonstrate the actuarial soundness of it. And although we would quibble with this, the study that was done in Pennsylvania unfortunately excluded supported education, supported employment. So the famous saying is, if you've seen one Medicaid program, you've seen one Medicaid program. We believe, and I think we can make a compelling case, that particularly for supported employment, there, I think, have been 24, 25 multiple randomized trials to show that it's effective. And I think that we're gonna see this changing over time, although when we talk a little bit later about the experience our colleagues in Illinois have had, we're gonna see that there's also some issues there. So Medicaid-managed care, commonly available. The Inlouis service can get you close to a full coverage of the costs of the program. Judith, let's look at the special SMI SED waivers now. So as I mentioned earlier, CMS, the Centers for Medicaid and Medicare Services, provided guidance to state Medicaid directors in 2018. So almost two years ago, that they could use the 1115 waiver mechanism to finance team-based coordinated specialty care, specifically highlighting persons with severe mental illnesses, persons with first episode psychosis. The financing is cost-based in terms of the 1115 mechanism, and it requires that the program be implemented to identify and serve individuals quickly. So the notion is to get to people right away, that the approaches are integrated, and that they occur in specialty settings. And almost every CSC program would meet these criteria. So it fits very nicely into an 1115 package. And then again, outreach and education. If the use of the 1115, those non-client specific services can be covered by use of a Medicaid administrative funds. And Maine is a state that is in the process of pursuing an 1115 waiver. And Doug, I don't know, do you wanna say anything about what's happening in Maine around their 1115? Maine. There you go. You're with us now, Doug. Yeah, can we go to the next slide? I believe we have a slide on Maine. Nope, we go to CCBHC, I'm sorry. We may kind of- Yeah, we have a slide on Maine when we talk about the commercial side. Yeah, well, we clearly, you know, we initiated a program to help people with mental health issues Well, we clearly, you know, we initiated a program in the greater Portland area with the idea that this was just the first step and we would move towards a statewide network of services and quickly ran into the problem that we're dealing with today, which is the limitation on reimbursement. So we would get community mental health center very eager to do this, but then realizing we were not gonna be able to pay for it. And so that's been a big block. Because of this, and because of some kind of good relationships with some parents who had severely ill children and others and physicians in community and others, we got quite a bit of support in the state legislature. And our program manager, Sarah Lynch, and I spent some time in the state capitol meeting with legislators. And one in particular has become a real champion, but a number have been quite supportive. The idea that there would be legislation from the legislature to require that the state develop a cost-based case rate or bundled payment program for the state. It started in a somewhat adversarial way because we had an administration that was not at all cooperative. They were, you know, against expanding Medicaid and so on. We now have a more favorable administration, but this legislation is still underway. It's passed one of the houses and it requires main care that was Medicaid here, establish coverage. And they looked at the options of amending the state plan and concluded they were better off going the route of the waiver, the 1115 waiver. This gives states, and you have to, of course, spell out exactly what you're wanting to do with it, but it gives the state flexibility about how to use Medicaid funds in ways that otherwise might not be done. So that's been submitted, and we're hopeful that that will come through. And if it does, because of the federal match, that decreases the cost to the state substantially. So our hope is that particularly with this cost to the state coming down, through this approach, we will be able to get through with the legislature and get Medicaid in place doing this in Maine. And we'll come later to our efforts with commercial insurance. So that's been another area of work. Right, thanks, Doug. That's terrific. So the final Medicaid strategy involves certified community behavioral health clinics. And we talked about this earlier as the fourth example and the one that I incorrectly named in that slide. And this program is very nicely tailored for first episode services. And for many of the sort of team-based services that need to be applied for people who have more severe illnesses. And I'm thinking of things like multisystemic therapy, a sort of community treatment, etc, etc. So currently this is a demonstration program in 10 states. I think it was recently just expanded from eight to 10 states. And additionally, SAMHSA has a grant program that's separate from the demonstration program in which SAMHSA can designate clinics as CCBHCs and they have to meet the same criteria that the clinics are meeting in the demonstration. And I think you can see here in the slide that this very nicely fits because required services in the CCBHC are things like coordinated care coordination, outreach and public education. You have to have a relationship with school. We haven't talked about that much except when Doug was talking about duration of untreated psychosis and the importance of community involvement in terms of serving people. And that's required. School relationships are required in the CCBHC model. It has a strong focus on patient engagement and outreach support to have that happen as an explicit orientation towards recovery, etc, etc. Those are just some of the characteristics of what has to be embodied in a CCBHC program that so nicely fit the funding challenges that we have in terms of ordinary Medicaid strategies. In the demonstration states, the CC, coordinated specialty service, we have a lot of Cs in this presentation. The coordinated specialty clinic could be required by the state as an evidence-based practice. And then the mechanism for funding it, the services that are provided by the CCBHC have to be covered at full cost. And you can include in those costs training, technical assistance and program evaluation costs. So those are allowed costs in the CCBHCs. Salaries in CCBHCs are at market rate. And so if many of the clinics around the country, part of the difficulty they have in retaining individuals is that the salaries are really not at market rates. Here salaries can be set at market rates. And so that helps, we think. I think the data are not in yet on all of these features and what they ultimately cause to happen. But we think that that should reduce turnover, increase the longevity of people staying in the programs. The nice thing about this is, I said before, one of the sort of the good thing about first episode psychosis is that the incidence is relatively low. The bad thing about it is it's hard to get attention of insurers. But also it's not a program that you want necessarily offered at every community clinic. That's probably not an efficient way to organize the services, number one. And number two, it could potentially cause a lot of problems in terms of quality assurance, fidelity to the model, et cetera, et cetera. So one of the components of the CCBHC allows services to be delivered on contract with a collaborating specialty program. So if you have a CCBHC and you have a coordinated specialty care unit clinic in your area, the CCBHC can contract for those services at cost, but all of these cost components can be included. Oregon and New York were in the original demonstration program. They both have successfully used the CCBHC mechanism. They speak very, very highly of it. It's a demonstration program, and so we're going to have to see whether or not it goes national after the demonstration is over and the evaluation is done. If it does, I think it will be an emerging model in terms of the full funding of team-based CSC services. So four strategies in Medicaid, amend the state plan, have an in lieu of provision for Medicaid managed care, use the special 1115 waiver mechanism for people with SMI or SED, or use the CCBHC mechanism. Right now that's a grant and demonstration program, and if the evaluation turns out to be positive, and I'm hoping and thinking that it will, that will be a mechanism I think that will really support sort of the specialty freestanding clinic operation for these kinds of services. Now let's go to the next slide, Judith. So commercial insurance, you know, typically most of us who've worked in this field for a long time don't think an awful lot about commercial insurance. We have focused not exclusively, but largely on state general fund services and services that are reimbursed by Medicaid. However, because of the expansion of services of insurance coverage, I should say, to young adults under the Affordable Care Act, many people who present to first episode programs have commercial insurance. In the national evaluation that Westat and colleagues did of the CSC programs around the country, 42%, almost half, included some revenue from commercial insurance. And I think as Doug mentioned earlier, you know, typically that might be reimbursement for psychotherapy, for medication support, but it's a relatively limited benefit when compared to the coordinated specialty care and the team-based services that we're talking about here. Uncovered costs of CSC programs for delivery of these kinds of services can be seen as a cost shift onto public payers, right? So if we know there's an evidence-based program, we know that under the parity law, it should be adequately covered on commercial insurance. If it's not, supplemental funds from the Mental Health Block Grant or from state general funds have to be used to supplement those services, that's functionally a cost shift from the private sector onto the public sector. And because those private sector subsidies, public sector funds are not available for people who have no insurance or others who could benefit from the program. So given the rate at which this is represented in this population, which remember largely has not become disabled from their illness, and the whole point is to not have them become disabled where they would start to qualify for Medicaid or Medicare, depending upon their work history. Working with commercial insurance, and there's some exciting stuff happening on the commercial side. I'm going to give you three examples, and then we'll sort of end up with Maine, and Doug can talk about all the good work that he and colleagues have been doing on the commercial side in Maine. So we have three state examples, one from Illinois, one from Connecticut, and one from Maine. And let's do this, let's look at Illinois first. So Illinois has actually managed to get CSC services as a mandatory service in Illinois, starting in January of 2021. It means that it mandatorily has to be covered by a commercial insurance. This was a multi-year effort, and I think as Doug alluded to in terms of Maine, an important part of sort of moving things legislatively was developing some special relationships with people in the legislature who are very sensitive to these sorts of issues. And similar things happened in Illinois. Thresholds, the treatment program in Chicago, had a government relations staffer who spent literally four years working these issues, looking for different strategies, developing legislative support to move forward. And they had a comprehensive act, so it wasn't just an act about insurance, it was an act about a whole range of issues that related to children and young adults who were in crisis. And so that was also part of the strategy to sort of build as broad a constituency to support this because of the multiple issues that were addressed. In this bill, there's a mandate that's included that commercial insurers, as I mentioned earlier, have to pay for these services on a cost-based rate by January 1, 2021. And unfortunately, again, we see that supported employment, supported education were not included. And so, although this is a huge step forward, we're still going to have to subsidize those critically important components of the model in Illinois. And as I mentioned before, it was really a strategy of persistent work with the legislature there around developing, understanding the importance of these services and the need for a team-based approach. But it now has been enacted as part of a more comprehensive law, not just related to insurance exclusively. Judith? So, there's some very nice features of the Illinois Act. The Act allows for credentialing of an entire team, including peers, case managers, bachelors of social work, et cetera, under the team leader's credential. One of the issues involved in billing commercial insurance is credentialing and having appropriate credentials for various members of the service provision group to be able to enable them to bill. And that's a problem when you have teams that are varied in terms of the number of individuals and the backgrounds of the individuals who are delivering the services. So, one of the nice features here is that everybody is covered by the team leader's license. And that's an important and can be a heavy lift for billing commercial insurance. The Department of Insurance is very much involved in this. And then, again, for many of us who've worked in states for many years, we very seldom had anything to do with our Department of Insurance. But on the commercial side, they're very important because they're the regulatory agency. The law required that the Department of Insurance convene workgroups of providers and insurers and others to do things like develop medical necessity criteria and coding requirements. And that work has actually been going very well. We have a workgroup in PEPNAT that focuses on financing. We meet every month. And so, we've been watching and sort of doing a case study of the implementation of this new act. And, knock on wood, so far things have gone very well. The medical necessity criteria have been developed, continuing care, discharge criteria. They're close to arriving at a billing code. They're just technical issues with a selection of a code. We're really fortunate to have some great work done at the Meadows Institute in Texas that identified a code that's appropriate for these services. And hopefully that'll really expedite that discussion. And so, we're going to continue to watch that. But that's one example. So, in that example, a legislative mandate was engineered and successfully got through the legislature. Got the governor to sign it. And it looks as though that's going to go into effect the first of next year. Let's look at Connecticut. And again, Doug had mentioned this earlier, you know, our colleague, Vinod Shrihari, at the Yale STEP program, had data around the cost of the provision of these team-based services and contrasted that with information about persons who received usual care. And Vinod approached Anthem Blue Cross to see if they would be willing to pay for these services, obviously for people who are Blue Cross Blue Shield recipients, on kind of a pilot basis, just to see basically how well that it would work. And given the leadership in Anthem at that time, in Connecticut, and Vinod's persuasive arguments, they agreed to do it. Unfortunately, and this is another problem that we see potentially coming up, the Connecticut, the CMHC there really had never billed commercial insurance. And they didn't have the infrastructure necessary to bill commercial insurance. And so they declined essentially to participate. And this is an issue that we're going to have to continue to think about as we continue to pursue commercial payers, is that there is an infrastructure necessary to do that, that many specialty clinics may not have. So we're going to need to identify strategies for development and dissemination of technical assistance, for example, around that. Dr. Surhari has not given up, and he's pursuing a strategy, the last time we spoke, of approaching another big practice plan, basically, that's quite used to billing Anthem, to see whether or not we can have a, he can further pursue that. So in this instance, a researcher, an excellent researcher, approached insurance in his state. They were open to it. They ran into infrastructure problems, and he's trying to craft now a strategy to go around the infrastructure issue and to bill to a large practice plan. And then finally, Maine, and Maine used yet a third strategy to approach commercial insurance. We're lucky to have on our seminar, one of the principal architects of this strategy, which is still underway. A lot of the stuff we're talking about today, Doug, is still very much in action. So you want to talk about, we already spoke about the 1115. You want to talk about the strategy that you used in a contract renegotiation there? Yes. We made the case to the leadership in our medical center that this needed to be part of a renegotiation of all of the behavioral health services that was starting back in 2017 and going into 2018, that was being done to deal with costs of general outpatient care act services, IOPs, partial hospitalization, a wide range of services. Partly because this program had been in existence and was a certain positive regard and success here in Maine, going back to year 2000 with our predecessor, Dr. Bill McFarlane, doing a good job of pioneering this in this area. This was part of that negotiation. So that went through ultimately very successfully, completed in the end, in late 2018. And that meant that all the large insurance companies dealing with Maine had signed on to the idea of a bundled rate payment program for coordinated specialty care. What we saw subsequently was because of just many competing economic interests and then added onto by COVID, I think, but even before that was that their focus was very much, again, it's part of what we've been talking about, this being a group of disorders that are very important and costly and devastating, but nevertheless, the prevalence is relatively small compared to other things that insurance companies deal with. And the huge next step, which involved getting into all the details of medical necessity, credentialing, coding, building the structure to actually do this, they just weren't ready to put that energy in and basically stalled out on this. And so we're having to kind of, again, try to engage their attention in this. They're not saying it's not a good idea. They're just saying they're not ready to do it at this time. One of the things we're working on right now with one of the companies is to develop, and I think we'll go from one to the next with this, but we're starting with one, and one of the largest is to have a study with their particular patients looking at the paid claims for people with first episode psychosis. So when we look at patients with first episode psychosis under this particular insurance company who come into our system, or in most cases, through our psychiatric hospital, then we're going to look at the subsequent care utilization and costs in the subsequent year. And then we know, or we strongly suspect that we know what that's going to show. It's going to show a substantial number getting re-hospitalized, maybe about half, running up some very high bills, and that we have abundant evidence from the effects of coordinated specialty care decreasing hospitalization, both with our own data here in Maine, and then the RAISE studies and Dr. Srihari's study, all showing that when you do this, you see less hospitalization. And it basically makes the case that if you were doing this, it would have saved you many, many tens of thousands of dollars, more likely hundreds of thousands of dollars, even with a relatively small population in the state of Maine. So I've been working on that. I've gotten some good consultation and support from an organization here that serves as an intermediary or broker between large employer benefits managers and health insurance plans. They're helping us to basically make the case and get this noticed and recognized. So it's still a work in progress. I'm optimistic that in the shorter run, we'll get Medicaid in place, and that not too far down the road, we'll get commercial insurance in place, probably one company at a time. But I think when we get one or two involved with this, and then we can have more demonstration of the cost savings that they may gain by doing the right thing, I think we're going to get everybody in line. But that's my rosy optimism at this point. We thought we had this all wrapped up at the end of 2018, but the devil is in the details, and that's what we're dealing with right now. And hopefully some of the work that's getting done in Illinois might provide some templates for that conversation, as well as some other issues. Next slide, please, Judith. So another issue, and I would recommend a webinar that the Mental Health Technology Transfer Center's put on with Ken Duckworth, who's, Ken's the halftime medical director at NAMI National, and also a halftime consultant to the Blues in Massachusetts. And he did just an excellent presentation on what from a commercial payer's perspective would be required for them to pay for Coordinated Specialty Care. One of the concerns is if you're paying for CSC, everybody's delivering CSC, whether they're doing it right or not. And so things like fidelity certification, you can use these centers of excellence that we talked about to help make sure that the specialty clinics are, in fact, providing the evidence-based services as designed and as is appropriate for their population. And so that's something that just from a practical implementation point of view and mission creep considerations, I think will be important. So I think we've made the case, or we've tried to make the case, that these can be devastating illnesses. And then traditionally, we've not treated them until a person was already at stage four, already advanced and disabled. You know, the CMHCs got to the point where you couldn't get into care, state care, unless you were already significantly disabled. Now we have now evidence-based practices that have been studied extensively internationally, both in our own country, that have shown, at least in the short to intermediate term, to improve outcomes, that the improvement in outcomes is worth the increased cost. And the increased cost is modest, right? We're talking pennies per member per month for an insured population. And the benefit in terms of quality of life and other outcomes, such as employment and education, is definitely worth that small marginal cost, that there are at least four strategies that the states can explore in Medicaid to get full coverage for these costs. And there are some very promising things happening on the commercial side with regard to the availability of these services. So we'll continue to work on it. We've got, as I mentioned, an issue brief that was published by the SMI Advisor. And it summarizes many of the points that we've made here today with a little bit stronger focus on first episode services, specifically since we started with a more generic presentation here about a coordinated team-based services. Judith, I think that this is the last slide. There's the literature cited. The webinar will be available on the PEPnet and the SMI Advisor site if you want to come and look at any of these resources. Next slide. I can't remember if we had one or two. No, that's it. Yeah. And this is our... I think that there are quite a number of other studies that we referred to, and we'll make those available in addition to the ones that are on the PowerPoint. Yeah. So there's our email, so you can get at us if you want to, and we'd be happy to respond to any questions or concerns via email or Stephen and Kate, I think, have been gathering questions for us.

financing team-based services

serious mental illness

first-episode psychosis

funding strategies

Medicaid options

commercial insurance

cost-effectiveness

coordinated specialty care

non-billable components

legislative mandates

evidence-based services