This section of the report focuses on the utilization trends and cost statistics for mental health and substance abuse services provided within the State of Texas, specifically those provided by the LMHAs, contracted substance abuse providers, and NorthSTAR. In addition, we have provided an introductory comment that provides a high level overview of the services provided within the various Medicaid programs.
The caseload and cost data outlined on the following pages is from different data reporting systems with unique customary ways of reporting services, depending on whether services were provided by the LMHAs, contracted substance abuse treatment providers, or delivered through the NorthSTAR system of care. Therefore the data is not presented for comparative purposes, but instead reported to provide information on the utilization and cost trends within these systems of care.
The LMHA cost data is self-reported in accordance with the Cost Allocation Methodology (CAM). CAM was designed to use a standard format to provide LMHAs and DSHS uniform and comparable cost data52. CAM data, which captures all funds, including those from DSHS, is monitored and required to be reported accurately as outlined in the contract requirements between DSHS and the LMHAs. Therefore, this data does not necessarily represent how much it costs DSHS for the provision of services. Moreover, the funding to the LMHAs from DSHS may not be consistent with the costs incurred by the LMHAs to render the services since LMHAs use other funds such as grants or local funds to provide services.
Differences in the reporting of information include the following;
• The SPNs, as well as most network providers, submit claims or encounters to the Behavioral Health Organization (BHO) which reflect a negotiated rate for the services rendered by the provider;
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Page | 79 • NorthSTAR data reporting includes expenditures that the LMHA system of service does
not cover: emergency room care, community inpatient, and state hospital costs for Medicaid clients;
• NorthSTAR providers do not submit a document comparable to the CAM that outlines each provider’s cost to deliver a unit of service. NorthSTAR providers submit claims data for reimbursement for the service as do other Medicaid managed care programs;
• In addition to the CAM, LMHAs also submit CARE Report III which includes all self reported expenditures they make
• State hospital utilization is treated differently. The state allocates bed-days to LMHAs and the DSHS state hospital division calculates how many days were actually used. Theoretically, if an overage resulted in a financial penalty, then the penalty would be recorded as an expenditure in CARE Report III. Also Medicaid clients who are fee-for- service (not Medicaid managed care) will have their bed day costs charged to the DSHS funded allocation. t
• NorthSTAR program also receives a hospital bed-day allocation for DSHS eligible (non- Medicaid) population. The DSHS state hospital division calculates any NorthSTAR overage. Again as with LMHAs, if too many bed days are used there is the possibility of a penalty.
• For persons with Medicaid and served by the LMHAs, HHSC has data regarding Medicaid purchased ER and community hospitalization costs but DSHS does not report these data unless DSHS funded the service. However these data are not included in LMHA data reporting.
• NorthSTAR data system includes detailed pharmacy data reporting for all DSHS non- Medicaid recipients that is available to prescriber and drug quantity level.
Except where separately identified, the data shown below for NorthSTAR, LMHAs, and substance abuse contractors represents the expenditures incurred in servicing both the Medicaid and DSHS eligible populations. Each utilization review will begin with an overview of the total number of individuals served, the cost per unduplicated individual served, and other utilization and cost patterns of significance based upon PCG’s review of the data.
Overview of Medicaid Behavioral Health Utilization
The mental health and substance abuse services provided by the LMHAs and NorthSTAR take place in the context of a statewide Medicaid program that also pays for behavioral health
Page | 80 services. This section outlines high-level service trends within the Medicaid program in order to provide information on the breadth of services that Medicaid pays for and the number of consumers that access mental health and substance abuse services through this program/funding source.
The Medicaid statistics presented here overlap with the information within the analysis section of the report outlined on the following pages on the NorthSTAR, LMHAs, and substance abuse providers. This is due to the fact that Medicaid is an important funding source for mental health services provided by the LMHAs. The data provided by HHSC and DSHS was de-identified, thus, PCG was not able to determine the extent of overlap to determine an accurate unduplicated count of Medicaid recipients served across the Medicaid and DSHS systems of care. 53
Medicaid is a significant funding source within the behavioral health system. Data for 2008 provided by HHSC shows that Medicaid and CHIP spent approximately $186 million on behavioral health services for persons in fee-for-service, PCCM, managed care, and the Children’s Health Insurance Program (CHIP).54 The Table below shows the Texas Medicaid program makes substantial payments for services to persons with behavioral health issues. The Table includes data on all adult and children enrolled in fee-for-service (FFS) and primary care case management (PCCM) programs for all behavioral services.55 The dollars include case management, rehabilitation and other behavioral health services. The data indicates that there has been a consistent increase in both total funds and the number of persons served over the last four years. While the number of persons went up the last two years, expenditures per person have been relatively flat over the four year period.56
53
The analysis of service cost and utilization required complex data matching between DSHS and HHSC files. The results of the data matching did not seem to add much to an already complex report.
54
Information on managed care and CHIP behavioral health expenditures were not available for 2009 and subsequent years. The 2008 figures do not include case management and rehabilitation services.
55
These dollars are in incomplete representation of Medicaid funding since PCG was only provided behavioral health capitation data for some plans and cannot provide a definitive count of the behavioral spend in Medicaid managed care plans. Moreover, these expenditures are primarily for mental health since Medicaid did not have a broad substance abuse benefit.
56
Cost estimates provided by the LMHAs cannot be added to Medicaid expenditures to estimate total behavioral health spending since LMHAs receive funds from Medicaid.
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Table III.20 Medicaid Fee-for-Service and Primary Care Case Management Expenditures for Behavioral Health, 2008-2011 (does not include managed care)
Adults and Children FY2008 FY2009 FY2010 FY2011
Case Management and Rehabilitation $48,422,606 $56,457,805 $83,814,823 $85,769,966 All Other Behavioral Health Services $107,502,358 $106,562,431 $107,289,031 $102,563,473
Total Expenditures $155,924,964 $163,020,236 $191,103,854 $188,333,439
Total Number Adults and Children 155,042 152,554 165,293 176,646
Cost Per Person for Year $1,006 $1,069 $1,156 $1,066
Percent Change in Persons -1.60% 8.35% 6.87%
Percent Change in Cost Per Person 5.89% 8.19% -7.78%
Source:HHSC, Strategic Decision Support Division
In addition to FFS and PCCM programs, Medicaid also pays for behavioral health through its managed care program. Managed care companies report encounter claims which state which person uses what service but the claims do not contain cost information since the state payment to the managed care plans is through capitation payments which include a component to pay for behavioral health. The table below presents information on the combined number of persons using Medicaid behavioral health services. The number of unique persons in FFS/PCCM programs was added to the number of unique persons in managed care programs. The table shows that there has been a steady expansion of persons using behavioral health services over the four year period.57
Table III.21: Change in Number of Persons using Medicaid Behavioral Health Services, 2008-2011.
Adults and Children FY2008 FY2009 FY2010 FY2011
Persons in FFS/PCCM Program 155,042 152,554 165,293 176,646
Persons in Managed Care
Programs 61,507 73,034 83,691 94,194
Total Number Adults and
Children 216,549 225,588 248,984 270,840
Percent Change in Persons 4.17% 10.37% 8.78%
Source: HHSC, Strategic Decision Support Division
Overview of the Utilization of Substance Abuse Services and Mental Health Services
In the next table PCG has outlined the unduplicated count of individuals served from 2008 through 2011.
57
The table above could contain potential duplications of persons to the extent that persons shift programs during the year. Additional research would be required to analyze parameters estimating this shift.
Page | 82 The table shows that the state-funded behavioral health services provide services to large number of individuals. Approximately 555,000 persons received mental health services through an LMHA in the four-year period from 2008-2011 and approximately 127,000 persons received mental health services through the NorthSTAR program. Utilization of DSHS substance abuse services has declined in 2011 while the utilization of LMHA mental health and NorthSTAR substance abuse and mental health services has expanded. As the population in the State of Texas continues to grow, the demand for mental health and substance abuse services is also expected to continue to increase year to year.
In the table below, the four rows showing the “Unduplicated Total” are not the sum of the children and the adults. Some children become adults in the course of the year and these persons are counted once as a child and once as an adult. The rows showing the unduplicated total removes this duplicate counting and shows the number of unduplicated individuals that received services each year.
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Table III.22: Counts of Persons that Received DSHS-Contracted Substance Abuse Services and Mental Health Services from LMHAs and NorthSTAR 2008-2011
FY 2008 FY 2009 FY 2010 FY 2011