AG 2007 05 21 - Laserfiche WebLink

Home Browse Search

PBH Local Business Plan 2007 Management of state resources and federal block grants, including state psychiatric hospital and Alcohol and Drug Treatment Center funds by Piedmont began July 1, 2003, under a Memorandum of Agreement between the North Carolina Department of Health and Human Services and the Piedmont LME. This involves consolidation of state funding into a single payment stream. All State Psychiatric Hospital, Developmental Center, and Alcohol and Drug Treatment Center dollars are included in the prepayment arrangement. PBH has the flexibility to develop alternatives to institutional care with this funding. The Financial Model The model developed by PBH includes strategies to re-deploy existing dollars more efficiently and effectively, blending as many funding sources as possible under a single financial manager including categorical dollars, starting with Medicaid and state funding. Re-engineering the system away from high-cost and institutional use, to a community-based system involves the authority to manage the full continuum of care. The PBH LME serves as the payer of all claims and provides encounter data to the State system as astand-behind reporting and shadow claims system (not as a billing function). Our strategy is to develop a funding model that identifies the best ways to support this systems change and, at the same time, enable federal, state and local payers to contain their overall costs, while we achieve reimbursement and benefits management Flexibility. The Piedmont Cardinal Health Plan (1915 (b) Medicaid Waiver) and the Innovations Waiver, (1915-c Medicaid Waiver) are especially important in redirecting services into more efficient, best practice models of intervention. Capitation supports the type of creative flexibility necessary in a consumer driven system of care. Re-direction of Medicaid resources for adults with developmental disabilities and mental health and substance abuse problems through a waiver allows for flexibility for supportive services in less restrictive settings and development of more consumer directed options that reduce reliance on high cost, poor outcome, and facility-based services. PBH saved $4 million in Medicaid dollars the first year of waiver operations, not through denial of care, but through effective service management strategies. 95% of authorizations have historically been approved; the 5% denial rate includes authorizations denied for administrative errors. Per our contract with the Division of Medical Assistance, this savings was placed in a reinvestment account. PBH through the NC Division of Medical Assistance applied to the Centers for Medicare and Medicaid for authority to use the savings to provide an array of best practice services that are not in the North Carolina Medicaid Plan. This authority was granted in January 2007. With the availability of lower cost alternative services that are specifically designed to support consumers in community settings, PBH will be able to more effectively redirect consumers away from institutional care. A Self Managed System A self-managed system relies on educated providers who understand and operate in tandem with PBH Clinical Objectives. Ideally, this is a system where the structure, requirements and expectations are so well known, that extensive management and intervention are not required. Providers are involved in the management of the system with the LME, and share in strategies to meet performance objectives, review of the system performance, and problem solving. Providers participate with PBH through the PBH Provider council, the Clinical Advisory Committee and the Global Continuous Quality Improvement Committee. Provider participation in the ongoing operations of the PBH system is critical in developing strategies that will be effective in achieving our goals. Our joint purpose is to assure easy access, appropriate, high quality services for consumers, and the elimination of ineffective and poor outcome services and practices. ~' 5