SSI Managed Care Talking Points

This program will not be integrated with existing county services for persons with mental illness. The Governor’s Blue Ribbon Commission on Mental Health (BRC), the President’s New Freedom Commission on Mental Health and iCare, the sole pilot program for SSI managed care, have all noted the need to integrate funding and services across Medicaid and human services in order to effectively serve this population. The work of the MH/AODA redesign over the past 5 years has been aimed at addressing this issue. The consequences of failing to integrate these systems are many and significant. A few examples:

• County matched (and over-matched) services such as CSP, targeted case management, and crisis services are currently not included in iCare—individuals in CSPs are not allowed to enroll. The lack of the funds associated with these services, and the inability in the current system to capture the county share of these funds, undermines the MCO’s ability to do proper care management. iCare is only funded to do care coordination not the intensive case management necessary for many in the population and required by the CSP standards.
• Many non-Medicaid services, such as services in IMDs, residential treatment, or consumer-operated services are an integral part of the continuum of care. While iCare may pay for these services from the Medicaid capitation rate there are not really adequate funds to do so, since counties have funded these services. How would this be handled as the program expands? Would counties still be required to pay for these services even though they are not managing the person’s care? Why would they agree to?
• What would happen to individuals who go on and off Medicaid? If the HMO becomes the locus of care for persons on SSI and they lose their SSI because of going to jail, not meeting a monthly spend down, going off MAP, or an administrative error, will they have to change providers? Will the counties now be required to serve these individuals? How will this impact continuity of care?
• How is the county system impacted by this program expansion? Many counties utilize the Medicaid revenue from individuals on SSI to support their service systems. Since they remain responsible for large numbers of individuals who will not be eligible for SSI managed care they will have to continue to run a system with certain fixed overhead costs but with many fewer users. This will certainly impact any efficiencies counties are able to achieve and could undermine their service systems.

The program limits consumer choice—a critical value under the BRC. The LFB summary of the Governor’s budget notes that the savings assume that individuals will be mandatorily enrolled even where there is not a choice of MCOs. DHCF staff indicated that this is not their intent. We strongly urge that individuals not be mandatorily enrolled unless there is a choice of MCOs as is the case in every other managed care initiative.

Even if choice of MCOs is assured there is the potential for disruption of existing consumer - provider relationships. Many consumers have developed long term relationships with therapists and psychiatrists in the public and private sectors using Medicaid payments. While the provider/client relationship is an important aspect in all of health care it takes on even greater significance in the mental health arena because of the trust issues associated with deeply personal, emotional disclosure. Unless there is a requirement that the HMOs have an open network, these relationships could be severed causing serious setbacks in many consumers’ lives.

It does not appear that this program will implement or incorporate the Mental Health/ AODA system redesign that was set in motion by the Blue Ribbon Commission. In addition to examining the implementation of managed care concepts, that initiative has focused on implementing consumer recovery and involvement and prevention and early intervention. A proposal that takes away consumer choice is not in keeping with recovery principles. Also, a great deal of work has been done in developing assessment instruments and outcome measures - how will this work be incorporated?

More thought needs to be given to how this program expansion impacts the MH/AODA redesign efforts. As noted above, by siphoning off resources from the county system, the expansion of SSI managed care could weaken the already tenuous financing for MH/AODA services. Additionally we are concerned that the DHFS’ historical lack of resources dedicated to the redesign is jeopardized by the need to put resources into SSI managed care expansion. Does the DHFS have the resources to do both and to do both well?

We question the adequacy of the funding available for SSI managed care. We understand that iCare currently receives capitation rates that average to around $740 per member per month. As DHCF has demonstrated by their own analysis, for persons with serious mental illness this amount will not even cover the cost of their medications. While DHCF argues that by making the program mandatory and thus balancing these high cost cases with low cost users the funding will be adequate. But our experience suggests that the mental health system, including those components covered by Medicaid, is underfunded. Further, iCare’s experience is that people enter their program with tremendous unmet needs because of the limitations of the fee-for-service system. If these factors are correct it will be impossible to provide a decent level of services based on historical Medicaid expenditures.

We are concerned about what HMOs will want to take on this population and the accountability that they will have to the citizens in their service area. One of the major reasons for the recommendations of the Blue Ribbon Commission, namely that any managed care system for persons with mental illness be built around the county human service system, was a concern about large national HMOs coming into Wisconsin and taking over the Medicaid program. This created disruption and disaster for the mental health systems in a number of states. We do not want to see this happen here. Given the size and potential costs for the SSI population, we see this as a major risk. Public accountability and consumer and family involvement must be built into any contracts.

Finally, this program development has proceeded for over six months without public input. We are advised that plans have been developed for input through a committee structure. However, this has not been put into place. We urge you to implement this as soon as possible.