Strategies for Integrating and Coordinating Care for Behavioral Health Populations: Case Studies of Four States. D. Program Financing and Contracting

01/01/2014

Financing. CCNC and its predecessor program, Carolina Access, were initially funded through a 1915(b) managed care waiver. However, as of April 1, 2009, CCNC's core programs are now funded through a SPA (#NC-09-006). Medicaid (DMA) is the only source of funding for the program, though CCNC receives state and federal grants for specified initiatives. CCNC is working to expand services to other payers in the future (including Medicare and private insurers) and is currently piloting this approach in seven counties.

DMA funds CCNC's work through a PMPM fee. This fee is paid for each enrolled individual, not just those for whom CCNC actively coordinates care. DMA pays CCNC $12.85 PMPM for each ABD enrollee. A portion of the PMPM fee is earmarked to fund CCNC's behavioral health program. DMA pays CCNC a lower PMPM fee for each non-ABD enrollee (ranging from $0.24 to $9.01, depending on recipient category). CCNC, in turn, passes along a portion of the PMPM fee to the local CCNC networks to fund their activities. CCNC's two largest but most critical costs have been related to training and the development of its data and information systems.

To fund physicians' participation in CCNC's disease management and care coordination work, DMA pays each CCNC-affiliated practice $5.00 PMPM for ABD enrollees and $2.50 PMPM for non-ABD beneficiaries. DMA reimburses physicians for medical services on a fee-for-service basis, whereas the state is currently transitioning to a managed care carve-out for all mental health services (Shipman 2012).

Contracting arrangements. CCNC's central office holds the contract with DMA. The central office retains funds to carry out program-wide responsibilities that include informatics, analytics, program development, training, government relations, and marketing. CCNC's central office subcontracts with the 14 regional CCNC networks to carry out local services, namely care management and practice support. In turn, CCNC-affiliated practices (primary care medical homes) contract with both DMA and separately with the regional CCNC network (McCarthy and Mueller 2009).

CCNC network responsibilities. Under the terms of its contract, each regional CCNC network is responsible for managing enrollees' care, including linking them to a primary care medical home, providing disease and care management services, and implementing quality-improvement initiatives (Kaiser Commission on Medicaid and the Uninsured 2009). All CCNC networks are non-profit organizations, either independent 501(c)(3) organizations or part of existing community organizations, such as academic medical centers, federally qualified health centers (FQHCs), or public health departments. All local care management staff (including care managers, behavioral health coordinators, and network psychiatrists for the behavioral health program) are employed directly by the local network. Each network has its own leadership, including a board of directors, medical management committee, executive director, and a medical director. The board of directors includes representatives from the participating provider and community groups. At a minimum, each board must have a representative from the medical, community hospital, health department, and social services organizations from each of the counties the network covers. Most boards also include representatives from an LME, academic medical center, Area Health Education Center, or other health organization. The medical management committee includes representatives from the network's primary care medical homes. CCNC's statewide clinical advisory board, comprising the elected medical directors from each network, meets regularly to decide on new quality-improvement and disease management initiatives and to select clinical quality measures to be tracked across practices.

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