State Medicaid official-telephone interview

ATTACHMENT I

DEMONSTRATION END TELEPHONE INTERVIEW PROTOCOL
STATE MEDICAID OFFICIALS

This page has been left blank for double-sided copying.

Demonstration END telephone Interview questions - state MEDICAID officials

In the spring of 2019, follow-up telephone interviews will be conducted with state behavioral health officials to obtain feedback regarding CCBHC implementation in their state. Telephone interviews will address specific factors that shape CCBHC policies and implementation, and will focus on changes in key CCBHC implementation domains since the second (demonstration midpoint) interview. The interviewer will transfer the information gathered from the interviews into a Debrief Template that organizes data by criteria domain and corresponding research questions. The general protocol for demonstration end telephone interviews is presented below.

A. Introduction

1. Please describe your current role/position and responsibilities.

B. Implementation successes and barriers

1. Overall, how do you think the CCBHC demonstration implementation went in your state?

Probe for:

-Differences in implementation across CCBHCs within the state (e.g., urban vs. rural, type of clinic prior to CCBHC certification, populations served, etc.)

a. How did your experience compare with your expectations for the demonstration?

b. What kind of feedback have you received from CCBHCs since [insert month and year of the midpoint interview]?

c. What are some of the key successes the demonstration has had?

• What factors have played a role in demonstration successes?

d. What problems or barriers have CCBHCs in your state faced since [insert month and year of the midpoint interview]? 

• Were these barriers anticipated or unexpected?

e. What steps have been taken to address or resolve these problems?

• Have these actions been effective?

C. Demonstration administration

1. In previous interviews we heard that the state Medicaid office has been involved in monitoring compliance of CCBHCs with the certification criteria by [provide description from baseline and midpoint interviews]. Has this changed?

a. Have any challenges arisen for CCBHCs in maintaining certification or continuing to meet all of the certification criteria?

• If yes, what steps have been taken to address these issues?

2. How have consumers (including adults with serious mental illness [SMI] and those with long term and serious substance use disorders), family members (including of adults with SMI and children with serious emotional disturbances), providers, and other stakeholders (including American Indian/Native Alaskans, and other local and state agencies) been involved in ongoing demonstration implementation?

a. What critical issues have they raised?

b. How has their input influenced the demonstration in your state?

D. Staffing and access to care

1. Since [insert month and year of the midpoint interview], were there any changes with respect to how the state Medicaid agency monitored the staffing criteria for the CCBHCs?

a. Were there particular issues that arose?

b. Were there any regulations that needed to be changed to allow payment for CCBHCs?

2. Since [insert month and year of the midpoint interview], did regulations or policies regarding Medicaid payments need to be altered to accommodate the CCBHC model?

Probe about:

• Same day billing restrictions

• Payment for designated collaborating organizations (DCOs)

• Any other regulations/policies

E. Scope of services and coordination of care

1. What are some barriers that clinics in your state have faced in providing the full CCBHC scope of services over the course of the demonstration? Have any new barriers or issues come to light since [insert month and year of the midpoint interview]? 

2. Since [insert month and year of the midpoint interview], have there been any changes to provisions that your state makes for payment for care coordination? If yes, what changes?

Probe about changes:

• In general medical care

• In behavioral health

• Targeted to high users of care

a. How do the changes to these provisions compare with coverage for care coordination in CCBHCs?

3. In [insert month and year of the midpoint interview] we heard that your state [does/does not] have IT requirements for Medicaid reimbursable providers in general medical or behavioral health care. Have there been any changes to these requirements? If yes, what changes?

F. Quality of care

1. How were quality measures data collected during the demonstration?

Probe for the following:

a. CCBHC reported measures (9 required)

• New clients – days until initial evaluation/percent of new clients evaluated within 10 days

• Preventive care and screening: BMI

• Preventive care and screening: Tobacco

• Preventive care and screening: Alcohol

• Weight assessment/nutrition counseling; Phys Activity for child/adolescent

• Child/adolescent: MDD-Suicide risk

• Adult: MDD-Suicide risk

• Depression screening and follow-up plan

• Depression remission- 12 months

b. State reported measures (12 required)

• Housing status

• Follow-up after discharge from emergency department for mental health

• Follow-up after discharge from emergency department for substance use disorders

• Plan all-cause readmission rate

• Diabetes screening for individuals with schizophrenia or bipolar disorder using antipsychotic meds

• Adherence to antipsychotic medication for individuals with schizophrenia

• Adult (21+): Follow-up after hospitalization for mental illness

• Child/adolescent: Follow-up after hospitalization for mental illness

• Follow-up for children prescribed ADHD medication

• Antidepressant medication management

• Initiation/engagement of substance use disorder treatment

• Patient/family experience of care (Survey Measures)

c. Who is responsible for collecting quality data when care is covered by an MCO or provided by a Designated Collaborating Organization (DCO)?

2. How was this data used?

a. Reporting to CCBHC?

b. Compliance monitoring?

c. Quality bonus payment?

d. Public reporting?

e. Other benchmarking?

3. How was quality of care information being used to improve clinical performance?

a. Did any issues arise with respect to collecting quality measures?

4. How did the state Medicaid office evaluate CCBHCs’ capacity to report quality measures with acceptable validity and reliability, in adherence to the agency’s expectations?

a. Were there particular populations of interest?

b. Were there concerns about the validity or timeliness of the data?

c. Did the state utilize any other systems for monitoring the quality of behavioral health care?

5. Since [insert month and year of the midpoint interview], how has information on CCBHC quality measures been shared among various state agencies, with CCBHCs and with the public?

a. How has CCBHC quality data been shared between clinics, managed care organizations, state Medicaid offices and state mental health departments?

6. In [insert month and year of the midpoint interview] we heard that there [are/are not] required quality reporting systems for Medicaid in your state. Have these requirements changed? If yes, how?

a. What are the requirements?

b. In behavioral health?

c. What has been done with the information to contribute to quality improvement?

7. How has the state Medicaid office collected, reported, and used CCBHC information on service utilization?

a. How does the state Medicaid office identify that a claim is coming from a CCBHC (e.g., have new codes been created to identify CCBHCs)?

b. How are CCBHC encounter records (or procedure codes) specified and processed (i.e., as opposed to claims for PPS)?

c. How will CCBHCs use data to inform population health management?

G. Cost and payment

1. In [insert month and year of the midpoint interview] we heard that cost reporting requirements for community behavioral health clinics in your state include [provide description from baseline and midpoint interview]. Have any requirements changed? If yes, how?

a. What is the content of current cost reports? 

Probe for the following:

• Total cost (e.g., per quarter, per year)

• Cost by resource

• Cost per consumer/provider/encounter

b. How do these compare with CCBHC cost reports?

c. Did CCBHCs encounter any difficulties with respect to cost reporting? Please describe.

d. Who is responsible for collecting/reporting cost data when care is covered by an MCO or provided by a DCO?

2. Have there been any changes to funding mechanisms for behavioral health care in your state since [insert month and year of the midpoint interview]? If yes, how?

a. In what ways do these differ from the PPS for CCBHCs? For example, how does the PPS differ from existing funding mechanisms for CMHCs?

b. How does the PPS for CCBHCs differ from existing funding mechanisms for specific types of behavioral health services?

Probe about:

• Peer support

• Day treatment/partial hospitalization programs

• Social services for people with serious mental illness

3. In [insert month and year of the midpoint interview] we heard that the process used for setting and revising payment rates for CCBHCs [provide description from baseline and midpoint interview]. Has this process changed in any way? If yes, how?

[If not answered above]

a. What data sources were used to derive initial rates?

b. How are rates being calculated for payment stratification of by patient severity, outlier payments and quality bonus payments?

4. We heard that cost data are being collected and used for rate setting by [provide description based on baseline and midpoint interview]. Has this changed since [insert month and year of the midpoint interview]? If yes, how?

a. Are data being collected to update rates? Rebalance payments? 

b. How are cost data being used for rate revisions?

c. How are outliers being defined and identified? 

5. Have you encountered any issues regarding payment with Managed Care Organizations (MCOs)? If yes, please describe.

Probe for specific issues depending upon:

• Type of MCO

• Types of services provided

• Patients enrolled with multiple MCOs

• Duplication of MCO services or payments

• Confusion regarding how MCOs determine what amount they are to pay to CCBHCs

• Actuarial certification letters

• Amount of capitation payment associated with CCBHC services

6. Have CCBHCs encountered any issues regarding payment of DCOs in your state through the CCBHC prospective payment system? Please describe.

1. If yes, what steps have been taken to address/resolve these issues?

2. How do the state and clinics handle billing if a client is receives services from more than one DCO in a single day?

7. Have there been any challenges related to claims or PPS payments for dual enrolled (enrolled in both Medicaid and Medicare) populations? What about recipients of 1915(c) Waivers?

a. If yes, what steps were taken to address/resolve these issues?

8. Have CCBHC costs been consistent with your expectations? Please describe.

9. Did CCBHC costs change in your state change from the first to the second year of the demonstration? How?

a. Were changed expected or unexpected?

b. What factors do you think contributed to changes?

H. Data availability

1. Have reporting requirements for CCBHC encounters changed since [insert month and year of the midpoint interview]? If yes, how?

[Assess for any changes to the following:]

a. How are CCBHC PPS claims reported and identified in claims data?

b. How are encounters recorded?

c. Does the state monitor utilization to identify potential unbundling of care, i.e. care that should be covered by the PPS that is billed outside of the PPS?

d. How does the state monitor care provided by DCOs and payments to DCOs?

2. What data are available to capture current consumer and payer spending across multiple providers and settings? Has this changed since [insert month and year of the midpoint interview]? If yes, how?

3. What data are available for measuring non-Medicaid or dual enrolled (enrolled in both Medicaid and Medicare) populations? Has this changed since [insert month and year of the midpoint interview]? If yes, how?

4. What is the current timeline for availability of claims and encounter data? 

5. Have you identified any new sources of comparison data since our last discussion?

I. Sustainment

1. What are your plans regarding sustaining any aspects of the CCBHCs after the demonstration ends?

a. What barriers or challenges might affect CCBHC sustainability?

b. How might those barriers/challenges be overcome?

c. What factors might facilitate sustainability?

J. Interviewee feedback/open discussion

1. What have we missed? What else do we need to know that we haven’t asked you?

2. Is there anyone else from the state office(s) of mental health and substance abuse services who should be included in these interviews?

3. Is there anyone else from the state office(s) of Medicaid who should be included in these interviews?