Analysis of Early Warning Indicators
First Quarter 2000

 

CHART 1 - MA ELIGIBLES ENROLLED BY COUNTY

This chart depicts the number and percentage of MA eligibles enrolled in HealthChoices during the First Quarter 2000. The numbers come from Quarterly Monitoring Report 6, Number of MA Eligibles Enrolled in HealthChoices as of the Last Day of the Quarter.

CHART 2a-h - AUTHORIZATION OF SERVICES

Methodology

The graphs depict the number of unique individuals per 1000 members who received authorization for a particular level of care in the HealthChoices program in Southwest Pennsylvania during the Quarter.

The numerator is the number of unique individuals who received services for a specific level of care in a single county during the Quarter as reported in the Behavioral HealthChoices Quarterly Monitoring Report 4, Number of Unduplicated Clients Authorized. The denominator is the number of the eligible population for a county as reported in the Behavioral HealthChoices Quarterly Monitoring Report 6, Number of MA Eligibles Enrolled in HealthChoices as of the Last Day of the Quarter, divided by 1000. For children's services the population is the average number of eligible children from ages 1-17 years old as reported in the Behavioral HealthChoices Quarterly Monitoring Report 6, Number of MA Eligibles Enrolled in HealthChoices as of the Last Day of the Quarter.

Example: For Allegheny county 50 of every 1000 members were authorized for outpatient services by the behavioral health managed care organization during the First Quarter, 2000 of the HealthChoices program. This number is derived from Quarterly Monitoring Report 4 J8 divided by Quarterly Monitoring Report 6 J9, multiplied by 1000.

It should be noted that the measures are not expected to indicate the exact number of persons who received treatment in the Quarter. Rather it is anticipated that these measures will allow for a comparison of counties and assist in determining where difficulties with services are more likely to be present.

These numbers do not reflect true utilization. Some members may be authorized for a service but not follow through to receive the service. This is common for outpatient services particularly substance abuse services. This will lead to a higher rate of authorization as compared to actual utilization.

High and Low Rates of Authorization - A low rate of authorization is defined as a rate of authorization less than fifty percent of the mean rate of authorization for the ten counties in said quarter. Low authorization rates are marked by horizontal stripes.

High rates of authorization are defined as a rate of authorization greater than double the mean for the ten counties in said quarter. High rates of authorization are marked by vertical stripes.

A County trends toward a low rate of authorization if the County met the criteria for a low rate of authorization (authorization less than half the mean for the entire HealthChoices population) for a particular service in two successive Quarters.

Summary of 1999

The number of unique individuals authorized for all levels of service was reported, on a quarterly basis, during 1999. The service categories included: Outpatient Mental Health, Outpatient Mental Health services for children, Inpatient Mental Health, Partial Hospitalization Mental Health, Outpatient Substance Abuse, Detoxification, Children's Behavioral Health Rehabilitation Services (BHRS) and Intensive Case Management and Resource Coordination (ICM/RC). The rate of authorization per 1000 members was compared among the ten counties that participated in SW HealthChoices and each county was compared to itself over time.

Outpatient Mental Health:
One County, Fayette, met the criteria for low rate of authorization (less than 50% of the mean for the total eligible population) in the First Quarter. No other counties met the criteria for a low or high rate of authorization during the year. However, Outpatient Mental Health Services for all eligible SW HealthChoices members declined 29% between the Third and the Fourth Quarter. CCBH attributed the decline to their policy of authorizing twelve months of outpatient services for persons with histories of long standing outpatient services. Most authorizations in the Fourth Quarter would be for new members and not reflect the members transitioned into HealthChoices earlier in the year.

Fayette County reported that the EWP Outpatient Mental Health authorizations prompted a review of their Outpatient Services. When the HealthChoices program began in Fayette County, there were only 2 primary providers of Outpatient Services located within the county of Fayette. Although members were free to cross over county lines and access other providers of Outpatient Services in the VBH Network, it became apparent to the county that additional providers were needed within the county to meet access standards. During 1999, two new in county providers were added to the network providing Outpatient Psychiatric Services to members in Fayette County.

In addition, Fayette County conducted studies that focused on the reason members fail to receive Outpatient Services within 7 days of a request. The review indicated that the most frequent reasons members failed to receive Outpatient services within 7 days were that they decided not to keep the appointment, requested an appointment at a later time, or reported that they no longer felt the need for services once a crisis was resolved

Inpatient Mental Health:
Greene County met the criteria for low rate of authorization in the Fourth Quarter. No other counties met the criteria for low or high rate of authorization during 1999. The rate of authorization for Inpatient Mental Health Services for all SW HealthChoices members increased 11% from the Second to the Fourth Quarter. The rate increased from 7.5 per 1000 members to 8.3 per 1000 members. The rate of Inpatient Mental Health authorization for CCBH increased 23% from 9.1 per 1000 members in the Second Quarter to 11.2 per 1000 members in the Fourth Quarter. It should be noted that SW HealthChoices was not mandatory until the Third Quarter 1999 and therefore the severity of illness in the population likely varied and may have influenced the rate of admission to Inpatient Mental Health Services.

Partial Hospital Mental Health:
Two counties Greene and Beaver met the criteria for low rate of authorization in the First Quarter. No county met the criteria for low or high rate of authorization in the other quarters.
Outpatient Drug and Alcohol:
Fayette County met the criteria for a low rate of authorization for all four quarters of 1999 and trended toward a low rate of authorization. Indiana County met the criteria for low rate of authorization for the First, Third and Fourth Quarter and also trended toward a low rate of authorization. No other Counties met the criteria for low rate of authorization in the Fourth Quarter. Greene County trended toward a low rate of authorization in the first two quarters, but not in the Third or Fourth Quarter.

Detoxification:
Greene County met the criteria for a low rate of authorization for all four-quarters of 1999 and trended toward a low rate of authorization. Indiana met the criteria for a low rate of authorization in the First, Third and Fourth Quarters. Armstrong and Fayette Counties met the criteria for low rate of authorization in the Third and Fourth Quarters. These Counties trended toward a low rate of authorization. In addition, Westmoreland met the criteria for low rate of authorization in the Second and Fourth Quarters.

VBH has added specific questions to the CST survey tool to determine preferences for locality in obtaining D&A services with a Federally Qualified Health Center (FQHC) in Greene County.

The low rate of authorization for Outpatient Detoxification Services in Fayette County may be explained by the absence of a service provider within the county. VBH is in the process of contracting and credentialing an in county Detox service provider. Detox authorizations are expected to increase when local services become available.

Children's Behavioral Rehabilitation Services (BHRS):
The rate of authorization for BHRS services for the entire SW HealthChoices population increased 30% between the Second and Fourth Quarters, from 13.7 per 1000 members in the Second Quarter to 17.7 per 1000 members in the Fourth Quarter. It should be noted that HealthChoices was not mandatory until the Third Quarter 1999 and, therefore, the severity of illness in the population likely varied and may have influenced the rate of BHRS.

No counties met the criteria for low rate of authorization during the Third and Fourth Quarters. Indiana County met the criteria for high rate of authorization (authorization rate twice the mean for the entire HealthChoices population) and Westmoreland County met the criteria for low rate of authorization in the First Quarter. Fayette County met the criteria for high rate of authorization in the Second Quarter.

Outpatient Children's Mental Health Services:
The number of children authorized for Psychiatric Outpatient Services decreased 15% between the Third and Fourth Quarters for the HealthChoices population. Fayette and Indiana Counties met the criteria for low rate of authorization in the First and Second Quarters and trended toward a low rate of authorization. Greene County met the criteria for low rate of authorization in the Second Quarter. No counties met the criteria for low rate of authorization during the Third and Fourth Quarters.

Intensive Case Management:
Greene County trended toward a low rate of authorization in all four-quarters of 1999. Fayette and Beaver Counties trended toward a low rate of authorization for the First, Third and Fourth Quarter. No other counties met the criteria for a low or high rate of authorization during 1999.

Fayette County has taken the following actions to enhance utilization of ICM and RC services: Since January of 1999 when HealthChoices was implemented the County hired 1.0 FTE Adult ICM and 1.0 FTE Children's ICM. Fayette County has also monitored the availability of ICM and RC services. ICM and RC services are available within 7 days of referrals. VBH of PA and Fayette County have not received any complaints or grievances regarding denials of care for ICM or RC services.

Fayette County and VBH are conducting a study to determine if inpatient readmission rates are lower for members who are receiving Intensive Case Management or Resource Coordination services at the time of readmission. In addition, the County is reviewing utilization of ICM/RC services by the "High Utilizer" population.

First Quarter 2000 Analysis

Outpatient Mental Health:
The decline in authorization in the Fourth Quarter 1999 was reversed in the First Quarter 2000. The rate of authorization of Outpatient Mental Health services for all eligible SW HealthChoices members increased 38% from 31 per 1000 members in the Fourth Quarter 1999 to 42 per 1000 in the First Quarter 2000. The rate in the First Quarter 2000 was similar to the rates in the Second Quarter (43 per 1000 members) and the Third Quarter 1999 (44 per 1000 members). No counties met the criteria for low or high rates of authorization in the First Quarter 2000.

Inpatient Mental Health:
The trend toward increased authorization for Inpatient Mental Health services for the entire SW HealthChoices population continued in the First Quarter 2000. The rate of authorization for Inpatient Mental Health services increased 11% from 7.9 per 1000 members in the Third Quarter 1999 to 8.6 members per 1000 in the First Quarter 2000. The rate of authorization for Inpatient Mental Health services for CCBH increased 16% from 10.1 per 1000 members in the Third Quarter 1999 to 11.7 members in the First Quarter 2000. This rate increase represents 150 greater incidents of inpatient admission in one quarter. The rate of authorization for Inpatient Mental Health services for the counties managed by VBH remained stable varying from 6.0 to 6.2 per 1000 members during the same time period. Increased rates of authorization for CCBH Inpatient services and stable rates for VBH Inpatient services is evident in the three quarters since HealthChoices has been mandatory for the entire Medicaid population. CCBH indicates that their contract requires they authorize at least the initial 48 hours of any 302 that has been approved by a physician. The increase in Inpatient admissions corresponds to increases in involuntary admissions for CCBH.

Indiana County met the criteria for low rate of authorization in the First Quarter 2000.

Partial Hospital Mental Health:
No counties met the criteria for a low or high rate of authorizations.

Outpatient Drug and Alcohol:
The rate of authorization for Outpatient Drug and Alcohol services has shown an upward trend in three of the last four quarters. The rate for all SW HealthChoices eligible members increased 20% from 6.2 authorizations per 1000 members in the Third Quarter to 7.5 authorizations per 1000 members in the First Quarter 2000. The rate of authorization for Outpatient Drug and Alcohol services increased 26% for CCBH and 13% for counties managed by VBH during the same time period.

Indiana County has met the criteria for low rate of authorization for all five quarters since HealthChoices began. Greene County has met the criteria for low rate of authorization for the Fourth Quarter 1999 and the First Quarter 2000. Both counties trend toward a low rate of authorization. No other counties met the criteria for a low rate of authorization.

Detoxification:
Greene County has had a low rate of authorization for Detoxification services in all five quarters since HealthChoices began and trends toward a low rate of authorization. Indiana and Fayette counties have had a low rate of authorization for the past three-quarters and also trend toward a low rate of authorization. In addition, Westmoreland County has had a low rate of authorization for the past two quarters and trends toward a low rate of authorization.

Children's Behavioral Rehabilitation Services (BHRS):
The rate of authorization for BHR services increased slightly (2%) between the Fourth Quarter 1999 and the First Quarter 2000. No counties met the criteria for a low or high rate of authorization.

Outpatient Children's Mental Health Services:
The rate of authorization for Outpatient Children's Mental Health Services for the entire SW HealthChoices population increased 21% from 26 per 1000 members in the Fourth Quarter 1999 to 32 per 1000 members in the First Quarter 2000. The change was similar for both BH-MCOs. The increased authorization reversed a decrease in the Fourth Quarter 1999. The rate of authorization in the First Quarter 2000 was similar to the rate during the Third Quarter 1999, 31 authorizations per 1000 members.

Intensive Case Management:
The rate of authorization for Intensive Case Management services for the entire SW HealthChoices population increased 18% from 11 authorizations per 1000 members in the Third Quarter 1999 to 13 authorizations per 1000 members in the First Quarter 2000. The rate of authorization for CCBH increased 15% form 15 authorizations per 1000 members in the Third Quarter 1999 to 17 authorizations per 1000 members in the First Quarter 2000. The rate of authorization for the counties managed by VBH increased 22% from 8 authorizations per 1000 members in the Third Quarter 1999 to 10 authorizations per 1000 members in the First Quarter 2000.

Greene County met the criteria for a low rate of authorization for all five quarters since HealthChoices began. Beaver County met the criteria for a low rate of authorization for the last two quarters and the first two quarters of the HealthChoices program. Both Counties trended toward a low rate of authorization. No other counties met the criteria for a low rate of authorization for ICM services in the First Quarter 2000.

CHART 3a-b - PERCENT OF MEMBERS FOR WHOM A REQUESTED SERVICE WAS DENIED

Methodology

Denial information was obtained from the Behavioral HealthChoices Quarterly Monitoring Report 5, Number of Unduplicated Clients Authorization Denials.

Analysis
Summary of 1999

The percentage of members that were denied services for the entire SW HealthChoices population in 1999 was low, but increased from 0.7% in the First Quarter to 1.7% in the Fourth Quarter. It should be noted that the PA definition of denial includes circumstances when the provider receives a lower level or lesser amount of service than initially requested. In many managed care programs this circumstance would not be considered a denial.

The distribution of denials remained similar throughout the year. Most denials were for inpatient services. Inpatient Hospital Detox was denied from 6.0% to 11.8%. However, the percentage of members denied the service decreased in all four quarters of 1999. Inpatient Mental Health was denied at a rate from 4.4% to 8.9%.

Recommendation for denial of BHRS and Residential Treatment Facilities (RTF) require an independent Impartial Review by a DPW consulting psychiatrist. Of the 41 Impartial Reviews conducted in 1999, 3 agreed with the provider, 26 agreed with the MCO, and 12 requests resulted in a recommendation from the Impartial Reviewer which varied from both the Provider and the MCO. Of the 26 MCO denials upheld for the year, 4 cases were denied because the service was not covered under the recipients' benefit package or required information to determine medical necessity was not submitted.

The following services were denied at a rate of less than 1% throughout the year: Outpatient Mental Health, BHRS, Crisis Intervention, Family-Based Mental Health, Outpatient Drug and Alcohol, Mental Health Case Management and Clozapine Support Services.

First Quarter 2000
The percentage of members that were denied service was essentially unchanged in the First Quarter 2000 (1.7%) as compared to the Fourth Quarter of 1999 (1.6%).

The distribution of was similar to the prior year. Inpatient services were the most frequently denied services. Inpatient Mental Health services were the most frequently denied service at a rate of 9.0%. Six percent of Inpatient Hospital Detox services were denied. Residential Detox services were denied at a rate of 4.6%. Children's residential services were denied at a rate of 3.6%. This was the first quarter that they were denied above a rate of 1%. Mental Retardation Behavioral Health Children's service was denied at a rate of 9.1%. However, service is rarely authorized and this represents a denial for one person. There were 13 Impartial Reviews of BHRS and Residential Treatment recommendations for denials conducted during the First Quarter. Of those 1 agreed with the provider, 9 agreed with the BH-MCO and 3 requests resulted in a recommendation from the Impartial Reviewer who varied from both the Provider and the MCO. It should be noted that the number of denials of BHRS and RTF will not necessarily correspond to the number of Impartial Reviews because Impartial Reviews are logged in upon receipt and the denial is not recorded until the outcome of the Impartial Review is submitted to the BH-MCO.

Grievances

Methodology

Grievance information is obtained from Pennsylvania HealthChoices Aggregate Encounter Report 35.

Analysis
Summary of 1999

The specific services that were grieved are not included in the data set. However, given that most of the denials were for inpatient services it is likely that the grievances were for denied inpatient services. Forty percent of denials were grieved in the First Quarter 1999. The percentage of denials that were grieved dropped to 32% in the Second Quarter and stayed at 30% for the Third and Fourth Quarters.

Trends varied for each MCO. The percentage of denials that were grieved, in Allegheny County, managed by CCBH, continued to drop from 54% in the Second Quarter, 35% in the Third Quarter to 18% in the Fourth Quarter. CCBH surmises that the continued decline in grievances was related to improved communications among providers, care managers, and physician advisors. The percentage of denials that have been grieved, in the nine Counties managed by VBH of PA, increased from 10% in the Second Quarter, 26% in the Third Quarter and 41% in the Fourth Quarter.

First Quarter 2000
The percentage of denials that were grieved dropped from 30% in the Fourth Quarter 1999 to 22% in the First Quarter 2000. The percentage of denials grieved dropped for both BH-MCOs. The percentage of denials grieved for CCBH has declined in each of the past five quarters from 54% in the First Quarter 1999 to 18% in the Fourth Quarter 1999 and 10% in the First Quarter 2000.

The percent of VBH denials that were grieved decreased from 41% in the Fourth Quarter 1999 to 31% in the First Quarter 2000. The VBH trend of an increasing percentage of denials grieved that was observed in the prior three-quarters was reversed in the First Quarter 2000.

CHART 4a-c- ANALYSIS OF COMPLAINTS SW HEALTHCHOICES BH-MCOs

Methodology

Complaint information was obtained from the Behavioral HealthChoices Quarterly Monitoring Report 2, Summary of Member Complaints.

Analysis
Summary of 1999

The number of complaints that were reported by the BH-MCOs during the first year of HealthChoices was low. This finding has been confirmed with a variety of stakeholder organizations as reported by their members to the PA Office of Mental Health and Substance Abuse Services (OMHSAS). Thus, it appears to be a reflection of the program rather than a problem with the EWP complaint recording.

The BH-MCOs reported 13 complaints per month in the First Quarter. The complaints increased every quarter to 37 complaints per month during the Fourth Quarter. On average for 1999 the BH-MCOs received 25 complaints per month. This represents about 1 complaint each month per 10,000 members over the entire year. Eighty-four percent of the complaints were related to the quality of, or access to provider services. Both BH-MCOs received a similar number and distribution of complaints in the First, Second and Fourth Quarter. VBH received fewer complaints than CCBH in the Third Quarter.

Access to transportation was reported as a problem to Consumer/Family Satisfaction Teams and in member satisfaction surveys. Beaver County's investigation revealed many consumers do not distinguish between "medically necessary transportation" to services and general transportation needs. Beaver, Fayette and Allegheny counties all conducted follow-up activities related to transportation.

First Quarter 2000
The average number of complaints per month in the First Quarter 2000 increased to 53 per month, from an average of 37 per month in the Fourth Quarter 1999. This continues a trend of an increasing number of complaints that has continued each Quarter since the HealthChoices program began. Ninety-one percent of complaints were related to provider service and quality of care.

The number of complaints was nearly equal between the BH-MCOs. The average number of complaints for CCBH increased from 19 per month in the Fourth Quarter 1999 to 28 per month in the First Quarter 2000. The most common complaint was no participation in treatment planning that accounted for 26% of complaints (22 complaints). CCBH believes this may be a coding error because their review showed only one such incident in the quarter. The second most common complaint was provider billed member that accounted for 23% of all complaints (19 complaints). Those two categories accounted for nearly half of all complaints. CCBH conducted a focus provider relations and quality effort regarding member billing. CCBH believes this intervention will be reflective in the next quarter's data.

The average number of complaints for VBH increased 43% from 18 per month in the Fourth Quarter 1999 to 25 per month in the First Quarter 2000. Dissatisfied with treatment was the most common complaint and accounted for 11% of all complaints (8 complaints). VBH indicates seeing a growing trend in complaints about BHRS providers. They are developing mechanisms to gather more specific data.

CHART 5a-b - INVOLUNTARY ADULT INPATIENT PSYCHIATRIC ADMISSIONS PER 1000 ADULT MEMBERS

Methodology

The rate of involuntary adult admissions is a measure of the number of adults in each county who received Inpatient Psychiatric Services involuntarily during the Quarter divided by the total number of MA eligible adults in each County. The number of adult inpatient involuntary admissions is obtained from the Behavioral HealthChoices Quarterly Monitoring Report 1, Number of Admissions to Inpatient Psychiatric Facilities. The number of MA eligible adults is obtained from the Behavioral HealthChoices Quarterly Monitoring Report 6, Number of MA Eligibles Enrolled in HealthChoices as of the Last Day of the Quarter.

Summary of 1999

The average rate of adult involuntary admissions to Inpatient Mental Health services in a quarter for the entire HealthChoices SW population ranged from 2.6 to 3.6 per 1000 members. Beaver County maintained a high rate of adult involuntary admissions in all four quarters ranging from 4.6 to 5.4 involuntary admissions per 1000 members. Allegheny had the highest rate of adult involuntary admissions in the Third Quarter (5.0 admissions per 1000 adult members) and Fourth Quarter (4.9 admissions per 1000 adult members). Butler County had the highest rate of admissions (6.4 admissions per 1000 adult members) in the First Quarter but was close to average in the Second through Fourth Quarters of 1999.

First Quarter 2000
The rate of adults, for the entire SW HealthChoices population, that were involuntarily admitted increased from 3.3 per 1000 adult members in the Fourth Quarter 1999 to 4.5 per 1000 adults in the First Quarter 2000. The rate of adult involuntary admissions for Allegheny County, managed by CCBH, increased from 4.9 in the Fourth Quarter 1999 to 7.4 in the First Quarter 2000. The rate of adult involuntary admissions for the counties managed by VBH was essentially unchanged at 2.1 involuntary admissions per 1000 adult members in the Fourth Quarter of 1999 and 2.2 involuntary admissions per 1000 adult members in the First Quarter 2000. The increased rate of adult involuntary admissions in Allegheny County accounts for the increase in rates for the entire adult SW HealthChoices population.

Allegheny had the highest rate of adult involuntary admissions in the First Quarter 2000 followed by Beaver County with a rate of 4.7 involuntary admissions per 1000 adult members. The rate for Beaver County has been essentially the same for the past three-quarters. Indiana County had the lowest rate of adult involuntary admissions at 0.2 adult admissions per 1000 adult members. Greene and Washington Counties also had less than 1 adult involuntary admission per 1000 adult members. CCBH's contract requires authorization of at least the initial 48 hours of any 302 approved by a physician. Beaver County studies 49 consumers that were involuntarily committed from August through September 1999. They obtained information from the person initiating the 302 and information about the housing situation, case management, age, services, and diagnosis. In all cases the criteria for involuntary commitment was met. No conclusions could be drawn. A Vermont study of all involuntarily commitments found over 80% of the individuals had a history of treatment difficulties.

CHART 6a-c - 30 DAY INPATIENT PSYCHIATRIC READMISSION

Methodology

The rates for inpatient readmissions are the number of persons in a child or adult age group (0 - 17 y/o or 18 and older) who were discharged from a psychiatric inpatient facility in a quarter and subsequently readmitted to any psychiatric inpatient facility within 30 days of their discharge, divided by the total number of discharges, for that age group, within the quarter. The information is obtained from the Behavioral HealthChoices Quarterly Monitoring Report 3, Number of Discharges and Re-Admissions to Inpatient Psychiatric Facilities.

Summary of 1999

The rate of readmission to psychiatric hospitalization for adults and children for the entire SW HealthChoices program ranged from 14% in the First Quarter to 17% in the Third Quarter. It should be noted that HealthChoices was not mandatory until the Third Quarter 1999 and, therefore, the severity of illness in the population likely varied and may have influenced the percent of readmissions to Inpatient Mental Health Services during that the First and Second Quarters.

The percentage of children readmitted within 30 days to an inpatient psychiatric unit for the entire SW HealthChoices population ranged from 10% in the First Quarter to 14% in the Fourth Quarter. The readmission rates were lower than rates that have been found in Iowa. Iowa reported in October 1999 a monthly average 30-day inpatient psychiatric hospital readmission rate of 21% for children.

The percentage of children readmitted to inpatient for the nine Counties managed by VBH ranged from 6% in the Third Quarter to 13% in the Fourth Quarter. The percentage of children managed by CCBH (Allegheny County) that were readmitted to inpatient psychiatric hospitals ranged from 10% in the First Quarter to 15% in the Third and Fourth Quarters.

The percentage of adults readmitted to an inpatient psychiatric unit within 30 days for the entire SW HealthChoices population varied from 15% to 18%. The percentage of Medicaid inpatients rehospitalized within 30 days in Massachusetts from July 1997 to September 1999 was 17%. Iowa reported in October 1999 that 17% of adults were readmitted within 30 days if discharged from an inpatient psychiatric hospitalization, the same rate as Massachusetts. Both rates are similar to the percentages of readmissions in the SW HealthChoices program during 1999.

The percentage of adults readmitted to an inpatient psychiatric service for the counties managed by VBH ranged from 13% in the First and Second Quarters to 15% in the Third and Fourth Quarters. No trends among the counties were identified. The percentage of adults managed by CCBH (Allegheny County) readmitted within 30 days of discharge from an inpatient psychiatric unit, ranged from 17% in the First, Second and Fourth Quarters to 20% in the Third Quarter.

CCBH conducted an analysis of readmissions to inpatient care for children and adolescents, during the Third Quarter, to determine possible issues. Three areas were identified for improvement: 1) readmission from RTF placements; 2) inadequate inpatient discharge planning and 3) discharge plans not fully implemented. CCBH held technical assistance sessions with RTF providers to assist them in developing treatment strategies to manage member behavior within the facility thus avoiding inpatient admissions. CCBH has met with inpatient providers regarding discharge planning.

VBH conducted a focused study and determined that members readmitted within 30 days of discharge often did not follow discharge recommendations. VBH is investigating the specific reasons why recommendations were not followed.

There are a number of factors that could be associated with the changes in readmission rates. HealthChoices became mandatory in the Third Quarter. Changes in readmission rates could be associated with changes in the member population if members with severe mental illnesses chose to remain in fee for service until the program became mandatory. In addition, the changes could be attributed to seasonal or statistical variance. The BH-MCOs have initiated actions to lower the percentage of members that are readmitted to inpatient psychiatric hospitalization. The rate of readmission will continue to be trended.

First Quarter 2000
The percentage of inpatients that were readmitted to an inpatient unit within 30 days of discharge for the entire HealthChoices population was stable over the past three-quarters ranging between 16% and 17%. The percent of children readmitted to inpatient hospitalization for the entire HealthChoices population increased from 11% in the Third Quarter 1999 to 15% in the First Quarter 2000. The percentage of children, managed by CCBH, readmitted within 30 days remained stable at 15% for the last three-quarters. The percentage of children managed by VBH readmitted within 30 days ranged from 6% in the Third Quarter 1999 to 15% in the First Quarter 2000. No discernable trends were seen among the nine counties managed by VBH.

The percentage of adults that were readmitted to an inpatient unit within 30 days was 17% for the First Quarter 2000. This rate has been steady for the past three-quarters ranging from 16% to 18%. The percentage of adults, managed by CCBH, readmitted to an inpatient unit within 30 days was 19% and ranged from 17% to 20% during the last three-quarters. The percentage of adults, managed by VBH of PA, readmitted to an inpatient unit within 30 days was 14% in the First Quarter 2000 and ranged between 14% and 15% during the last 3 quarters. Forty-three percent of adults admitted to an inpatient psychiatric hospital in Washington County were readmitted within 30 days. This is the largest percentage of patients readmitted to an inpatient unit for any county, in a quarter, since HealthChoices began. However, given the small number of admissions (30) further trending is recommended. CCBH indicates they have not seen identifiable impact from their focus review of child/adolescent readmissions. They continue to see high no-show rates for follow-up appointments.

VBH-PA conducted a focus study of all inpatient admissions that occurred during the third and fourth quarters 1999. Lack of patient compliance with the discharge plan including medication management and appointment follow-up was the most significant issue contributing to the readmissions. Also, in approximately 25% of the readmission cases reviewed, follow-up appointments were not given prior to discharge.

In March 2000 VBH-PA aftercare coordinators began telephoning all members and/or outpatient providers after the inpatient admission to help assure follow-up is occurring. VBH has addressed discharge planning and documentation requirements in their provider newsletter as well as in their recent provider forums. VBH will be monitoring through the chart review process, compliance with documentation and appointment access.

Along with these actions, VBH is looking at individual facility readmission rates through our provider profiling process, and facilities that are not providing appointments to patients prior to discharge through an auditing process. Several pilot projects are under consideration. One initiative would include partnering with a network facility to pilot a comprehensive discharge planning program, and, in another, working with a county partner to look at outcome data for a mobile medication implementation. OMHSAS will be monitoring follow-up appointments after discharge of consumers from an inpatient psychiatric facility with a primary diagnosis of schizophrenia. The study, consisting of a medical record review, will be performed by the OMHSAS contracted external quality review organization, IPRO.

Chart 7a-c-- Racial Minorities Authorization for Services

Methodology

The number of unique individuals authorized, by racial designation, was obtained from the Behavioral HealthChoices Quarterly Monitoring Report 5, Number of Unduplicated Clients Authorized.

Analysis
Summary 1999

The percentage of minority members in each county that were authorized for any service in the Second through the Fourth Quarter was compared to the percentage of the same minority in the Medicaid eligible population. The most frequent minority designation in the HealthChoices population was Black, not of Hispanic origin (Blacks). The percentage of Blacks among the Counties in the HealthChoices eligible populations varied from 1% in Greene County to 45% in Allegheny County. The percentage for other minority groups within the HealthChoices eligible population was less than 1%.

Allegheny and Beaver Counties were the only counties in the Second through the Fourth Quarters with a difference between eligible and authorized population that was more than 2%. The differences are shown in the table below.

Percentage of Blacks Eligible and Authorized for Services
Quarter2 Quarter3 Quarter 4
County
Eligible
Authorized
Eligible
Authorized
Eligible
Authorized
Allegheny
45.4%
36.6%
45.5%
36.6%
45.4%
35.9%
Beaver
20.0%
14.5%
20.1%
16.3%
20.0%
15.5%

The differences between the percent of blacks eligible and authorized to receive behavioral health services may be related to minority access to services in a behavioral health setting or other factors. The distribution of blacks among the MA categories could influence the findings. For example, a high percentage of whites may be assigned to a SSI MA category, in a particular county. Behavioral health needs tend to be higher for disabled MA eligibles as compared to other MA categories. Under this circumstance the percent of authorizations may be higher for whites without an underlying problem with minority access to behavioral health services.

In addition, a recent study (African-Americans More Likely to get Counseling From General Health Providers, Medical Care/Medscape Wire, December 21, 1999) the authors reported that blacks are more likely to seek mental health services from their primary care physicians, as compared to whites. The EWP indicator does not include mental health services provided by primary care physicians. However, it is likely that a similar inclination to use primary care physicians was present among blacks in all counties.

The number of minorities in some counties was too low for this indicator to provide reliable information.

First Quarter 2000
In the first Quarter 2000 Allegheny and Beaver continued to show a difference between the percentage of blacks that were authorized to receive a behavioral health service and the percentage of Blacks that participated in HealthChoices. The differences in the First Quarter 2000 were similar to those found in the prior three-quarters that were measured and are shown below. CCBH has convened a stakeholder task force on cultural competency. Focus groups with minority representatives are planned.

Percentage of Blacks Eligible and Authorized for Services
Quarter 1-00
County Eligible Authorized
Allegheny
45.5%
36.0%
Beaver
19.9%
15.6%

Beaver County funds the Family Services System Reform project which targets young parents in population centers with high African American representation. They have begun discussions with a provider to expand services to these areas and are examining provider recruitment initiatives for hiring minority staff.

In addition, in Washington County a larger percentage of blacks received a behavioral health authorization (13%) as compared to the percent that participate in the HealthChoices program (10%).

CHART 8a-b -- NUMBER OF CLEAN CLAIMS PAID IN 30 DAYS

Methodology:

Claims information was obtained from HealthChoices Behavioral Health Program Analysis of Claims Processing Reports. The percent of claims paid at 30 days is the number of claims paid divided by the number of clean claims received. The claims paid data is delayed one quarter as compared to the other early warning indicators.

Analysis
Summary 1999

The PA claims standard at 30 days is 90% of clean claims paid. The EWP reviewed clean claims for each county during each month of the First, Second and Third Quarter of 1999. During the first three quarters CCBH was able to meet the PA standard for seven of the nine months that claims data was submitted, and paid 89% and 75% of claims in the other two months. CCBH met the PA standard from March through September of 1999, the last month that was included in the 1999 EWP report.

VBH paid for services in nine counties. Each county was measured on a monthly basis. VBH met the PA standard for 22% of the months measured for the nine counties and paid 80 to 89% of claims for 37% of the months measured. Less than 80% of claims were paid in 41% of the months for the nine counties that were measured.

First Quarter 2000
The First Quarter 2000 report includes clean claims data from the Fourth Quarter 1999. Allegheny County met the PA standard of 90% claims paid within 30 days during two months in the Fourth Quarter 1999 (October and November). During December 79% of Allegheny claims were paid within 30 days. During the month of December Allegheny County has a large number of clean rejected claims. Allegheny paid more than 90% of claims by 45 days in all of the months reported.

Two of the nine counties managed by VBH met the PA standard for clean claims paid in 30 days (Armstrong County for November and December, Indiana County for December) during the Fourth Quarter 1999. All counties failed to meet the standard in at least one month during the Fourth Quarter 1999 and seven counties failed to meet the standard for all three months in the quarter. The percent of clean claims paid within 30 days for a county in a month ranged from 45% to 93%.

VBH reports correction of claims processing errors has been a major priority. The major thrust of the VBH claims payment timeliness issue was directed at correcting the data fields so that the claims payments are appropriately reflected in monthly reporting. This was accomplished by January 1, 2000 and improvements will most likely be experienced in the ensuing Year 2000 Quarterly Reports. Many other actions have been established to address the timeliness of claims processing. These actions include:

Chart 9a-e-- Provider Surveys

Methodology

Sixty providers from two levels of care are selected each quarter to receive a telephone provider survey. Two different surveys are used. One survey is designed to address the satisfaction of clinicians with the BH-MCO. The other survey focuses on the satisfaction of administrators with the BH-MCO. The survey is organized in categories of related questions, such as claims or the quality of services. The analysis of a category is based upon the sum of results for all questions within the category. Analysis of individual questions is also included.

The clinical and administrative surveys are offered, by telephone, to thirty providers, each from separate agencies. For each quarter all of the agencies selected provide the same level of care. In practice, the surveyors have been able to reach about fifty providers in each quarter (twenty-five for each survey). All of the providers that have been reached have agreed to participate in the survey.

The forty- three-question survey focuses on the relationship between clinicians and the BH MCOs. Survey questions inquire about the provider's satisfaction with service authorization, the quality of care within the service network, provider relations, member services/care management and overall satisfaction. Provider responses are recorded on a 5 point Likert scale. A Likert scale allows a provider to choose among 5 levels of response from very satisfied, satisfied, neither, less dissatisfied and very dissatisfied. Providers that cannot be contacted after a minimum of 3 times are excluded from the survey.

The category Clinical Services consists of a subset of quality related questions that are directed at the provider's experience with specific clinical services. These clinical services include the availability of emergency, urgent, MISA, case management, children's services, BH MCO assistance to the provider with difficult cases, discharge placement for inpatient members who require outpatient drug and alcohol services and discharge placement for inpatient adults with a mental health diagnosis.

The providers were considered satisfied if 80% percent or more, of the providers with experience were satisfied or very satisfied in response to a question or category of questions. The respondents were deemed to be dissatisfied with the BH MCO if twenty-five percent or more were dissatisfied or less than 50% percent of the respondents, with experience, were satisfied in response to a question or category of questions.

The administrative survey is conducted with 30 administrators, each quarter from separate provider agencies. All of the agencies selected provide the same level of care. The fourteen-question survey focuses on the provider's satisfaction with claims, provider relations, grievance and complaint processes, service authorization and overall satisfaction. Provider responses are recorded on a 5 point Likert scale. Providers that cannot be contacted after a minimum of 3 times are excluded from the survey.

Many of the respondents to both the clinical and administrative surveys did not have experience with all of the questions. The analysis is based upon those providers that had experience. Therefore, the results from a particular question or category are derived from smaller numbers than total respondents. The numbers of respondents with experience were too small for the results to achieve statistical significance. Rather the results are intended to give an impression of the provider's opinions. It is anticipated that problems may be identified through additional inquiries guided by the results from the provider surveys.

Provider Surveys Analysis
Summary of 1999

Provider surveys were begun in the Third Quarter 1999. Inpatient adult and child mental health clinical providers were surveyed during the Third Quarter 1999. This group was chosen because inpatient providers are required to have frequent contact with the BH MCOs and these providers require a high degree of network clinical services for their patients upon discharge. Provider satisfaction or dissatisfaction with BH MCO services was more likely to be identified among providers from this level of care.

Clinical providers' responses to survey questions indicated that inpatient providers were overall satisfied with CCBH, availability of emergency, children's and MISA services. Providers reported that the CCBH staff was courteous and helpful. Providers' responses indicated dissatisfaction with the availability of physician reviewers, clarity of provider performance expectations and training opportunities. Clinical providers were satisfied with the courtesy and helpfulness of VBH Provider Relations staff and the availability of children's services. Providers expressed dissatisfaction with the ease of authorization, availability of physician review, timeliness of payments and calls answered, assistance with complex patients, availability of training, and notification of policy changes.

Behavioral Health Rehabilitation Services for Children (EPSDT) administrative providers were surveyed during the Third Quarter 1999. This level of care was chosen because of the importance of this service to children and their families and to understand the impact of mandatory managed care for these providers.

Administrative providers met the criteria for provider satisfaction with the CCBH credentialing process. Provider response met the criteria for dissatisfaction for survey questions regarding timeliness of CCBH grievance process and the responses to questions regarding claims. Provider response to questions regarding VBH met the criteria for dissatisfaction for rate and accuracy of payment; timeliness of payment, answers to questions and resolution of claims complaints; notification of changes in policy; clarity of quality management goals; availability of training and provider forums. Update - Second Quarter 2000: CCBH indicates their monitoring of grievance management shows 100% compliance with Act 68 and HealthChoices standards.

Outpatient Drug and Alcohol providers were surveyed for both the clinical and the administrative surveys during the Fourth Quarter of 1999. CCBH met the criteria for provider satisfaction for: service authorization, availability of emergency services and physician review, appropriateness and application of Medical Necessity Criteria, cultural competency, coordination with PH-MCOs, clarity of documentation, quality, clinical services, member services/care management, courtesy and helpfulness of provider relations staff and timeliness of calls answered. Provider response regarding VBH met the criteria for satisfaction for the following: availability of children's, emergency, MISA services and physician review; service authorization consistency with requests; courtesy and helpfulness of member services/care management staff; timeliness of calls answered and notification of changes in policy.

VBH met the criteria for provider dissatisfaction for overall satisfaction, timeliness of claims payment and dispute resolution, assistance with complex cases and discharge placement from inpatient hospitalization for adults with mental illness and members with substance abuse problems. Providers expressed dissatisfaction with CCBH notification of changes in policy and the clarity of quality improvement goals.

A small number of CCBH providers (three out of five providers with experience) expressed dissatisfaction with the availability of children's services. Although this is a small number of providers, CCBH will review access and capacity for drug and alcohol services for children and adolescents beginning March 1, 2000.

The provider survey questions regarding transportation met the criteria for dissatisfaction for both BH-MCOs in the two quarters that the survey was administered. Medically necessary transportation is the responsibility of the county Medical Assistance Transportation program (MATP). Counties, BH-MCOs and network providers share responsibility for coordination with MATP.

The administrative providers surveyed in the Fourth Quarter indicated that CCBH met the criteria for satisfaction for provider relations; credentialing; provider forums; timeliness of response to inquiries and complaint resolution; and clarity of pre-certification policies. Provider response to VBH met the criteria for satisfaction with the availability of training.

Providers surveyed indicated dissatisfaction with CCBH's consistency of payment with their fee schedule. Providers were dissatisfied with VBH consistency and accuracy of claims; timeliness of response to inquires, complaint resolution; and provider forums.

In summary the provider surveys were welcomed by the provider community and assisted the state to identify strengths with the BH- MCOs and the treatment system. In addition, the surveys provided an opportunity for providers to communicate in a methodical and comprehensive fashion their experience to the state-monitoring program.

First Quarter 2000
Due to the demand on resources to complete the SE and SW annual reviews, provider satisfaction surveys were not conducted during the first quarter of 2000. Provider satisfaction surveys of mental health inpatient providers will be conducted during the second quarter of 2000. An annual schedule has been developed to insure that provider satisfaction surveys are conducted in each quarter.

CHANGES IN BH-MCO POLICY

BH MCOs are required to report specific program changes to OMHSAS including:

Analysis
Summary of 1999

During the First Quarter changes were reported in three areas, hiring of key staff, introduction of formularies and changes in the complaint policy to expand reporting of verbal complaints.

Staff hiring and leavings were the most common changes reported by the BH-MCOs and Counties during the Second through the Fourth Quarters. CCBH Medical Director and Allegheny County HealthChoices Medical Directors changed. VBH hired an Ombudsman for each county, a Service Manager, an Account Executive, four new Peer Advisors and significantly increased staff for the Behavioral Health Rehabilitation Services unit. Beaver County hired a new Director for the Consumer Satisfaction Teams, and an Ombudsman. The QM Specialist in Beaver County and Complaint and Grievance Coordinator resigned. The SW Behavioral Health Corporation hired a MIS staff person.

The Bureau of Drug and Alcohol Programs modified the Medical Necessity Criteria for drug and alcohol services.

OMHSAS and the Health Department's, Bureau of Drug and Alcohol Programs (BDAP) jointly issued instructions to county MH/MR offices and the Single County Authorities regarding reporting of client outcomes for priority populations served by drug and alcohol providers. The Single County Authorities have modified their reporting systems to include selected HealthChoices outcome indicators, which will be electronically transferred to OMHSAS while preserving confidentiality.

Allegheny Counties' plan for system-wide mobile crisis was approved and the process for structuring the program and developing sub-contracts was initiated. The multi-agency approach became fully operational in the First Quarter 2000.

First Quarter 2000
OMHSAS finalized and distributed the Medical Necessity criteria for Intensive Case Management and Resource Coordination. The criteria were developed with input from all stakeholder groups. Training is being held for the HealthChoices counties and their provider networks and tested by county ICMs. The criteria are to be implemented by July 1, 2000 unless alternative medical necessity criteria has been submitted and approved by OMHSAS.

OMHSAS announced the decision to delay the implementation of psychiatric rehabilitation services as an in-plan HealthChoices service until January 1, 2002. The implementation is necessary to gather more accurate data to project rates and refine medical necessity criteria. The January letter outlines the actions OMHSAS is taking to gather necessary data and its plan to continue with state sponsored training to assist counties with building provider capacity prior to implementation.

There were no reports of major staffing or policy changes from the counties or their BH-MCOs in the first quarter 2000.

CATEGORIES OF FEEDBACK FROM STAKEHOLDERS

Summary 1999

The PA OMHSAS Bureau of Operations and Quality Management engaged with many community groups to address a variety of managed care-related issues and concerns. The groups that provided feedback included but was not limited to: Medical Assistance Advisory Committee, OMHSAS CASSP Advisory Committee, SW Consumer/Family Satisfaction Teams, SW Alliance for the Mentally Ill, HealthChoices Members, Western Region CSP Committee, Western Pennsylvania Coalition for Children's Advocacy, PA Health Law Project, Benova Advisory Committee, Medical Assistance Transportation Program Providers, HealthChoices Providers, BH-MCO Provider Forums, BH-MCO's, Southwest Consumer Health Coalition, DPW and Health Department Program Offices, Office of Children Youth and Families, PA Health Department's Bureau of Drug and Alcohol Programs, Office of Mental Retardation, Office of Social Programs, Office of Medical Assistance Programs, County Children and Youth Agencies (CCYAs), County MH/MR Administrators, County Commissioners and County Solicitors, Single County Administrators for D&A services, SW providers, OMHSAS, State Psychiatric Hospitals, SW BH-MCOs, and Southwest Physical Health Managed Care Organizations

Access
Service:

Behavioral Health Rehabilitation Service (BHRS):

Quarter 1
Issue: Legal advocates expressed concern that the contracting for BHRS services below the Medical Assistance rate could impede access to service.
Action: OMHSAS monitoring teams determined that only one existing provider of BHRS providers declined to sign a contract. This issue was closely monitored, and counties were asked to report if any provider complaints were received. Update: In January 2000 Six County and Greene raised BHRS rates to the fee-for-service level. Beaver and Fayette rates remain the same. All counties remain in compliance with the HealthChoices access standards.

Quarter 3
Issue: The Philadelphia Disabilities Law Project filed a statewide class action lawsuit related to the provision of BHRS in both HealthChoices and non-HealthChoices areas. Among the claims is an allegation that children are not able to receive authorized services within a reasonable timeframe.
Action: The OMHSAS Pittsburgh Field Office is working with counties and DPW legal council regarding the allegations.

Children-In-Substitute-Care:

Quarter 1
Issue: Enrollment for children-in-substitute-care was stagnating because Letters of Agreement had not been finalized.
Actions: The Western Regional County Office of Children, Youth and Families (OCYF) visited each county to help coordinate interface with Benova and to implement the enrollment process. This required resolving eligibility issues, processing information with Benova, and selecting a PH-MCO and a primary care physician (PCP) for each child. After a slow start-up, all children-in-substitute-care are enrolled and none required auto-assignment.

Quarter 1
Issue: All of the required Letters of Agreement with County Children and Youth Agencies and Juvenile Probation Offices (JPO) had not been finalized at the beginning of HealthChoices.
Actions: The BH-MCOs and counties developed a boilerplate agreement for all ten counties to facilitate ease of coordination. For one county, a cross-DPW-office team met with the local solicitor to develop mutually agreeable language.

Quarter 2
Issue: It was determined, in the Second Quarter, that a large number of Children in Substitute Care were coded incorrectly in the Client Information System (CIS) and consequently had not been enrolled in SW HealthChoices.
Actions: The OCYF, Office of Medical Assistance and OMHSAS corrected the data problem. All Children-in Substitute Care could be enrolled during the voluntary period and none were auto assigned.

Quarter 3
Issue: One county, that is not the HealthChoices contractor, had yet to finalize the Letters of Agreement for coordination of physical and behavioral health care for children-in-substitute care.
Actions: DPW will continue to work with the county regarding execution of these agreements and provide any necessary technical assistance needed. Update: Washington and Greene counties are proceeding with the dissolution of the Joinder agreement. Greene County has agreed to execute necessary written HealthChoices agreements. Service coordination has been effective despite the lack of a signed agreement.

Quarter 3
Issue: OMHSAS continued to receive requests for clarification of payment issues for children in substitute care. Two additional payment issues surfaced regarding specific drug and alcohol payment responsibilities and responsibility for OCYF inter-state children in the HealthChoices zone.
Action: OMHSAS and the OCYF distributed a document and matrix to clarify responsibility across the child serving agencies for children in and outside the HealthChoices zone. The two new issues, drug and alcohol payment and OCYF inter-state children in the HealthChoices zone are being researched and written clarifications will be provided. Update: Training was held for all SW child-serving agencies in April 2000. The drug and alcohol payment issue remains under review and data is being collected on inter-state children to determine the scope of the issue and payment responsibility.

Psychiatric Rehabilitation Services:

Quarter 3
Issue: Psychiatric Rehabilitation Services are due to beginning January 1, 2000 for the HealthChoices counties. Counties and BH-MCOs requested information regarding the program standards and Readiness Review Requirements.
Actions: OMHSAS conducted a two day training sessions for potential providers and a one-day training for BH-MCOs and county staff to review the service requirements and the Readiness Review criteria. Update: OMHSAS announced, in January 2000, Psychiatric Rehabilitation implementation will be delayed until January 2002 in order to further study rate issues and to strengthen medical necessity criteria.

Admissions to State Psychiatric Hospitals:

Quarter 2 - 4
Issue: Counties admitting to Mayview State Hospital reported problems accessing timely admissions for county residents some of whom are covered under HealthChoices.
Actions: OMHSAS met with Mayview and the affected counties. The bench mark for an admission established by the hospital is seven days. The hospital agreed to try to honor all admissions within seven days and develop a tracking system to monitor admission timeliness. In the last quarter the average wait time in Allegheny County was less than seven days and the range of admissions was from 2 to 15 days. Other counties were encouraged to create similar reports if admissions were an issue for their county. Counties served by Torrance were asked to report if additional delays occur.

Medical Necessity Criteria for Drug and Alcohol:

Quarter 4
Issue: The Department of Health's Bureau of Drug and Alcohol Programs (BDAP) issued updated criteria for the PA Client Placement Criteria, the medical necessity criteria for BH HealthChoices.
Action Taken: BDAP and OMHSAS hosted two training sessions for all SW BH-MCO staff, county staff and others regarding the new criteria that should be used by the BH-MCOs.

Methadone Treatment:

Quarter 1
Issue: Increasing access to methadone treatment services is a goal in several SW-HC counties.
Action: A new methadone treatment center was licensed in Fayette County. A Washington County methadone provider considered being in the HC network announced that it did not wish to participate in the MA program. This will affect access for both Washington and Greene County residents. Update: The Washington County Methadone provider is now in the VBH network.

Medication/Pharmacy:

Quarter 1
Issue: The PH-MCO formularies were not final and approved at the beginning of HealthChoices implementation.
Actions: OMHSAS and OMAP worked to expedite review and approval. Copies of the formulary were put in the HealthChoices library. Proxy calls were made to the PH-MCOs to test how a consumer's request for formulary information was addressed. OMHSAS worked with Benova and the PH-MCOs to ensure all member service representatives understood the formulary issue.

Quarter 2
Issue: Advocates reported confusion about changes being made in PH-MCO formularies. Two PH-MCO's had requested approval for formulary changes
Action: PH-MCO's will present information to advocates about changes in the formulary to the Benova Advisory Committee members once written approval for the formulary has been approved by OMAP.

Quarter 4
Issue: The National Alliance for the Mentally Ill Southwestern Pennsylvania (NAMI-SW) reported a reduction in pharmacy locations from one PH-MCO making access difficult for persons with mental illness.
Action Taken: The PH-MCO did notify members of this change and is in the process of completing a new pharmacy directory. OMAP is reviewing the pharmacy network to determine adequacy. HealthChoices access standards are being met. The PH-MCO is working on a case-by-case basis with behavioral health members to bring their current pharmacy back into the network or find a new pharmacy in close proximity. OMAP is closely monitoring this transition and NAMI-SW is assisting in identifying members with access concerns. Update - Second Quarter 2000: NAMI-SW reports no further complaints of access since this action was taken. The PH-MCO is mailing new directives in July 2000 and semi-annually thereafter.

Transportation:

Quarter 1
Issue: The PA Health Law Project pointed out discrepancies between the HealthChoices requirements and the way in which current county Medical Assistance Transportation Program (MATP) programs work.
Actions: An interoffice DPW work group was established. New MATP requirements were recently issued statewide with two training sessions being held for the MATPs.

Quarter 2
Issue: The counties (MATP) operating procedures were not always consistent with HealthChoices access standards for MA members.
Action: The DPW Office of Social Programs modified the MATP operating criteria to meet HealthChoices access standards. OSP conducted two training sessions for all MATPs in the state to inform them of the draft standards. MATP providers were instructed to send plans for compliance and budget projections to the OSP for review. Update: OSP issued final revised MATP requirements and conducted SW training for transit authorities. County plans were successfully able to support a budget increase for MATP. All county plans demonstrate compliance with the new criteria.

Quarter 3
Issue: The county MATP procedures are being modified to conform to HealthChoices access standards. Counties have been asked to closely monitor transportation needs of MA members.
Actions: Allegheny County surveyed provider's concerns with transportation. Based on survey results case manager supervisors were trained to assist consumers with transportation needs. Beaver county CST reported transportation problems. After reviewing the complaints it was discovered that some transportation complaints were not HealthChoices related. Fayette and VBH for Greene met with the local MATP to have input into their plan for expansion of transportation services. Fayette MATP participated in a cultural sensitivity training regarding people with mental illness and drug and alcohol problems. Butler reported some problems with MATP payment to providers. Update: Second quarter 2000 - Butler reports OSP has been responsive to their request for timely payment.

BH-MCO Telephone:

Quarter 1
Issue: During the first three weeks of the HealthChoices program one BH-MCO exceeded the standard of all calls answered within 30 seconds.
Actions: The BH-MCO changed staffing patterns and reduced phone concurrent reviews resulting in continuous compliance with the quality assurance standard.

Quality:

Complaints:

Quarter 1
Issue: BH-MCOs were not following OMHSAS HealthChoices standards in that all complaints, even those where a member does not wish to file a written complaint, must be reported. BH-MCOs were following the less stringent Act 68 requirements for reporting complaints.
Action: OMHSAS clarified their policy to the BH-MCOs, which now track both verbal and written complaints.

Consumer/Family Satisfaction Teams:

Quarter 1
Issue: Some county C/FST groups reported that they were not clear about their role with the HealthChoices program and had received no commitment for payment of expanded services.
Actions: The monitoring team worked with individual counties to finalize written plans and assure financial resources were available. All plans were put in writing and financial commitments confirmed.

Payment:

Children:

Quarter 1
Issue: The payment responsibility for a small number of children was in question.
Actions: OMHSAS and OMAP monitoring teams coordinated care information to clarify payment responsibility. Provision of services was not impeded for the children. Most payment issues were resolved within several days.

Provider Claims Payment:

Quarter 3 - 4
Issue: Several stakeholder groups, individual practitioners, and the provider satisfaction surveys have surfaced issues about untimely payment by the BH-MCO. Complaints include documentation of third party liability (TPL) availability, late payments, and difficulty by providers in reconciling unpaid claims submitted.
Action: The OMHSAS monitoring team followed up on each identified provider payment complaint raised to the Monitoring Team. The monitoring teams have asked the county contractors to investigate. In some cases the claim submitted was not "clean" and therefore could not be processed, in other cases claims had been rejected due to third party liability (TPL) determination. OMHSAS provided written clarification (TPL) responsibility requirements and the MCO revised policies and procedures to discontinue a practice called "Coordination of Benefits" that was delaying payment. All counties not meeting the payment timeliness standard submitted plans of corrective action.

Enrollment:

Quarter 1
Issue: Behavioral health advocates expressed concerns about Benova, the Independent Enrollment Assistance contractor, regarding the lack of coordination with counties, behavioral health aspects of presentations to members and the response of their telephone staff to behavioral health questions.
Actions: OMHSAS, OMAP and Benova met and initiated the following actions. Benova staff met with each county to coordinate behavioral and physical health enrollment. Benova enrollment "scripts" were revised with increased information about behavioral health benefits. An enrollment form was developed. OMSHAS enhanced their monitoring and attended Benova Advisory Committee meetings. Following these actions immediate improvement was reported.

Request to Delay Auto-Assignment Date:

Quarter 2
Issue: In June, DPW began receiving requests from western constituents to delay the auto assignment of HealthChoices members. Some advocates were concerned that enrollment was lagging and that a large number of MA recipients would be auto assigned.
Action: DPW determined that a delay was not likely to increase voluntary enrollment and did not delay the start date. Benova used an aggressive telephone outreach campaign, and conducted an extensive number of enrollment sessions. Benova began using the revised enrollment presentation, which added additional information about BH benefits. By the end of the voluntary enrollment period Benova surpassed the DPW contract goal, enrolled 86% of all HealthChoices members and 84% of members in the category of SSI without Medicare. BH constituents reported being very satisfied with the Benova results.

BH-HealthChoices Member Handbooks:

Quarter 3
Issue: Reports from one county, a Consumer Satisfaction Team and the PA Health Law Project indicated that HealthChoices members were not receiving their handbooks in a timely manner.
Actions: Both BH-MCOs agreed to a weekly distribution system and to modify the computer logic to identify members in advance of enrollment. Members are now receiving handbooks in advance of enrollment. BH-MCOs also will provide copies of the handbook to the County Assistance Office, Consumer Satisfaction Teams, Consumer Drop-In Centers, and local providers to ensure availability. Update: There continue to be periodic reports from Family/Consumer Satisfaction Teams about members not receiving handbooks. Reports also indicate that many consumers are not familiar with the name of their BH-MCO or of the HealthChoices program so may not know what the handbook is for.

D&A Confidentiality:

Quarter 1
Issue: Pennsylvania requirements for D&A confidentiality exceed the federal guidelines and are often misunderstood by BH-MCOs and providers.
Actions: The Health Department, Bureau of Drug and Alcohol Programs and Bureau of Licensure provided consultation to revise BH-MCO forms and authorization process to comply with PA State law. Additional training will probably be required to further clarify new issues being raised.

First Quarter 2000
The OMHSAS Bureau of Operations and Quality Management receives input from a wide variety of community stakeholders, committees, and organizations. This section highlights the major issues raised in the quarter and the action taken to address each issue.

Access:

Transportation:

Issue: Fayette County Family/Consumer Satisfaction Team (F/CST) reported concerns by HealthChoices members about access to the Medical Assistance Transportation Program (MATP).
Action Taken: In working with the local MATP it was determined that recent advertising about the program had resulted in a higher volume of ridership than could be handled. The MATP hired additional staff and added routes to accommodate the need. Fayette County is revising their HealthChoices handbook and will include information about transportation. The C/FST also distributes brochures about the MATP program when it interviews members.

Children in Substitute Care:

Issue: SW children's providers from multiple systems and other stakeholder groups have expressed confusion about payment and coding for children placed within and out of the HealthChoices zone.
Action Taken: DPW developed chart and case examples to clarify payment and coding issues. The SW regional OMHSAS and OCYF jointly sponsored training to review the material, answer questions, and identify unresolved issues. All counties and child serving systems were represented among the 100 attendees. Many of the previous questions appear to be resolved and those not resolved have been identified for action. The session identified an unknown coding problem for children placed in shelters out of the county, and a suggestion to hold a specific session that would focus on CCYA and Juvenile probation officers issues. A focused session for JPOs and CCYAs is being planned.

Cultural Competence:

Issue: The Allegheny Family Center providers are interested in greater coordination with the HealthChoices and improved responsiveness for mutually served families.
Action Taken: The OMHSAS Deputy Secretary and staff, CCBH, and county representatives met to discuss how HealthChoices is working, barriers experienced and promising models that could be used with Family Centers. CCBH will continue working with the Centers to explore new models for service delivery. OMHSAS hopes these efforts will forward the agenda of making HealthChoices services more culturally relevant.

Quality and Appropriateness of Services:

Issue: Family members of children diagnosed with autism are advocating for the treatment needs of their children within Beaver and Washington Counties.
Action Taken: Washington and Beaver County representatives have meet with local autism family advocates to hear about the needs of their families and how the system is currently working for them. An on-going dialogue is being established.

Payment:

Issue: The VBH plan of corrective action on claims process timeliness continues to be monitored by the counties and OMHSAS.
Action Taken: Counties have conducted site visits to the Latham, NY claims center to observe all aspects of the process. VBH has established a PA specific claims unit of staff trained and dedicated to the PA contract specifications. VBH Member Service staff at the Trafford Service Center has been assigned to follow-up with providers on rejected claims to correct errors. Three provider forums on claims were held in the quarter. Counties are working with high volume providers to increase electronic submission of claims to reduce provider errors. The DPW Comptrollers Office has begun its SW claims audit process beginning with Westmoreland. The OMHSAS Annual Review included an extensive review of the plan of corrective action and executive management of claims. Improvement is now evident. However; several important systems issues remain to be resolved.

MCO Functions:

Act 68 Compliance:

Issue: Fayette County established a county-based unit of Care Managers to manage utilization of HealthChoices high-risk members. The unit is under the supervision of the VBH Medical Director. Clarification was needed to determine if Fayette County needed to be certified by Department of Health (DOH) as a Utilization Review Entity in accordance with Act 68.
Action Taken: The DOH reviewed the Fayette HealthChoices model and determined it does meet the definition for a Utilization Review Entity and was given 90 days to apply for certification. DPW has been working with the county to establish a new civil service classification for county-based care managers that is in compliance with qualifications required under HealthChoices.

HealthChoices Annual Review:

Issue: OMHSAS distributed Annual Review criteria and format to the SW HealthChoices counties. Each county is to conduct a self-assessment in preparation for an on site review.
Action Taken: Counties submitted their self-assessment to OMHSAS Regional Office. The site visit will occur in the second quarter. The review will have a program, finance, and information system section. Reviewers, in addition to OMHSAS, will include families, consumers, persons in recovery, families with children, OCYF, MR, BDAP and the DPW Controllers Office.

Early Warning Project:

Issue: OMHSAS in collaboration with the Health Care Financing Administration (HCFA), and Substance Abuse Mental Health Services Administration (SAMSHA) used the first year of SW-HC to test the concept of the Early Warning Project.
Action Taken: The pilot has been determined to be a success. Stakeholder groups report strong support for the report and the process of timely communication about HealthChoices. OMHSAS has modified information systems reporting requirements to eliminate less effective measures and incorporate the Early Warning measures that have proven to be effective. Early Warning will now be incorporated into the on-going Quality Management plan. Chester, Bucks, and Montgomery counties will begin reporting on the measures in the second quarter 2000 and Delaware and Philadelphia in July 2000. The report will incorporate the SE counties as they come on board. The Pennsylvania Community Providers Association has posted the Early Warning report on their web site (www.paproviders.org).

Status of Unreported Measures:

Homelessness among Serious and Persistently Mentally Ill: Data is being collected through POMS reporting. Test data will be shared with the counties next quarter. It is expected that reporting of this measure will begin in the third quarter.

Children Placed in Residential Treatment: Test data has been run. The template format is being finalized and will be distributed to the Counties in the second quarter of 2000. It is anticipated that they will produce a report for all of 1999 as well as the first three quarters of 2000 during the third quarter.

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