1

Exploring Behavioral Health Integration through Data

Mental Hygiene Administration Annual Conference

May 14, 2014Revised May 28, 2014

2

Public Mental Health System (PMHS)Overview

3

Public Mental Health System (PMHS)

• Serves, pays claims for Medical Assistance Eligible and select uninsured individuals– No Medicare (unless service not covered)– No Private Insurance

• Administrative Services Organization (ASO)– Authorizes all non-emergency services

• Based on MHA established medical necessity criteria

– Processes all PMHS claims– Submits to Medical Assistance for FFP

4

PMHS Consumers Served, FY 2013

• Over 152,000 People Served in FY 2013– 38% under age 18, 62% ages 18 and older

• 45% ages 21 and under

– 93% Medical Assistance, 7% Uninsured– $667 million in claims payments

• 90% Medical Assistance, 10% State Only

• About 1,800 people served yearly in 5 psychiatric hospitals, 2 RTCs; about 1,000 are resident each day

• Local Services through Core Service Agencies– $50 million in service and grant funds

• Current Analysis– Claims paid on behalf of 109,686 consumers ages 15 and over

5

Managed Fee-For-Service SystemFY 2013 Data

6

People ServedFY 2008 to FY 2013

2008 2009 2010 2011 2012 2013 -

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

56,076

63,185

73,107

81,799

89,342

94,127

43,030 44,696 48,451

52,157 56,077

58,385

Adults Childen and Youth

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Expenditures in Millions of DollarsFY 2008 to FY 2013

2008 2009 2010 2011 2012 2013 $-

$50

$100

$150

$200

$250

$300

$350

$400

$450

$290.50

$335.28

$373.28

$397.10 $411.38 $406.81

$210.84 $224.35

$236.52 $245.79

$258.30 $260.47

Adults Childen and Youth

8

FY 2013 PMHS DemographicsAge

Adults Children and Youth

20.0%

35.3%

31.6%

11.3%

1.7%

18 to 25 26 to 40 41 to 5455 to 64 65 and over

8.9%

50.4%

40.7%

0 to 5 6 to 12 13 to 17

9

FY 2013 PMHS DemographicsGender

AdultsPMHS Consumers by Gender

PMHS Consumers 15 years and Over

Children and Youth

PMHS Consumers by AgePMHS Consumers 15 years and Over

60.3%

39.7%

Female Male

42.7%

57.3%

Female Male

10

FY 2013 PMHS DemographicsRace

Adults Children and Youth

46.4%

50.1%

3.5%

Afr.Amer. White Other

52.6%41.1%

6.3%

Afr.Amer. White Other

11

FY 2013 PMHS DemographicsEthnicity

Adults Children and Adolescents

6.1%

93.9%

Hispanic Non-Hispanic

11.7%

88.3%

Hispanic Non-Hispanic

12

PMHS Services

• Mental Health Case Management (MHCM)• Residential Crisis Services (RCS)• Inpatient• Mobile Treatment Services/Assertive Community Treatment

(MTS/ACT)• Outpatient • Partial Hospitalization Program (PHP)• Psychiatric Rehabilitation Program (PRP)• Residential Rehabilitation Program (RRP)• Residential Treatment Center (RTC)• Supported Employment Program (SEP)

13

FY 2013 People Served

Total by Service Category Percent by Service Category

Sum exceeds 100% because people may be in more than one service.

Total unduplicated number is 143,645. Sum exceeds this number because people may receive more than one service.

MHCM

RCS

Inpatient

MTS/ACT

Outpatient

PHP

PRP

RRP

RTC

SEP

Other

- 50,000 100,000 150,000 200,000

4,233

1,713

10,125

3,490

145,643

1,995

21,361

4,388

700

3,195

898

MHCM

RCS

Inpatient

MTS/ACT

Outpatient

PHP

PRP

RRP

RTC

SEP

Other

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

2.8%

1.1%

6.6%

2.3%

94.8%

1.3%

13.9%

2.9%

0.5%

2.1%

0.6%

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FY 2013 Service Expenditures

Millions of $ By Service Category Percent of $ by Service Category

Total Expenditures: $667 Million

MHCM

RCS

Inpatient

MTS/ACT

Outpatient

PHP

PRP

RRP

RTC

SEP

Other

$- $50.0 $100.0 $150.0 $200.0 $250.0 $300.0

$6.5

$6.4

$143.5

$26.1

$258.1

$7.6

$149.1

$10.7

$50.3

$7.4

$11.3

MHCM

RCS

Inpatient

MTS/ACT

Outpatient

PHP

PRP

RRP

RTC

SEP

Other

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

1.0%

0.9%

21.2%

3.9%

38.1%

1.1%

22.0%

1.6%

7.4%

1.1%

1.7%

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FY 2013 PMHS ServicesCost per Person Served by Service

MHCM

RCS

Inpatient

MTS/ACT

Outpatient

PHP

PRP

RRP

RTC

SEP

$- $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000

$1,543

$3,734

$14,175

$7,487

$1,772

$3,787

$6,981

$2,428

$71,897

$2,304

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State Psychiatric FacilitiesFY 2013 People Served

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State Psychiatric FacilitiesFY 2013 Average Daily Population

• Eastern Shore Hospital Center - 59• Springfield Hospital Center - 231• Spring Grove Hospital Center - 354• Thomas B. Finan Center - 66• Clifton T. Perkins Hospital Center -238

– Maximum Security • Regional Institute for Children and Adolescents-

Baltimore - 31• John L. Gildner RICA Montgomery-20

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State Psychiatric Facilities

Adults Children and Youth

Female

Male

Afr. Amer.

White

Other

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

23.9%

76.1%

59.0%

37.1%

3.9%

Female

Male

Afr. Amer.

White

Other

0% 10% 20% 30% 40% 50% 60% 70%

36.2%

63.8%

45.3%

45.3%

9.4%

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Alcohol and Drug Abuse AdministrationOverview

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Defining Treatment Levels of Care

Early Intervention (0.5) – Outpatient counseling for individuals who do not meet criteria for a substance- use disorder, but who are at high risk for alcohol or other drug problems (e.g., DUI patients, school based early intervention).

Level I - Outpatient Treatment (I) – Nonresid ential, structured treatment services for less than

nine hours a week per patient. Examples include office practice, health clinics, primary care clinics, mental health clinics, and “step down” programs that provide individual, group and family

counseling services. Detoxification services are delivered in Level I.D.

Opioid Maintenance Therapy (I-OMT) – Medication- assisted treatment specific to opioid

addiction. Patients are medically supervised and engaged in structured clinical protocols. Services

are delivered under a defined set of policies, procedures and medical protocols. Methadone maintenance programs are an example of this level of care. Detoxification services are delivered in

Level OMT.D.

Level II - Intensive Outpatient (II.1) – A structured therap eutic milieu in an outpatient setting

that delivers nine or more hours of structured treatment services per patient, per week.

Partial Hospitalization (II.5) - Provides each patient with 20 or more hours of clinically intensive

programming per week based o n individual treatment plans. Programs have pre- defined access to psychiatric, medical and laboratory services. Detoxification services are delivered in Level II.D.

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Level III - Clinically Managed Low Intensity Residential Treatment (III.1) - Provides Level I

treatment services to patients in a residential setting such as a halfway house.

Clinically Managed Medium Intensity Residential Treatment (III.3) - Programs provide a

structured recovery environment in combination with clinical services; for example, a therapeutic rehabilitation facility offering long- term care.

Clinically Managed High Intensity Residential Treatment (III.5) - A structured therapeutic

community providing a recovery environment in combination with intense clinical services, such as a resid ential treatment center.

Medically-Monitored Intensive Inpatient Treatment (III.7) - Programs offering a planned

regimen of 24 hour professionally directed evaluation, care and treatment for addicted patients in

an inpatient setting, Care is delivered by an interdisciplinary staff to patients whose sub-acute biomedical and emotional/behavioral problems are sufficiently severe to require inpatient care. Detoxification services are delivered in Level III.7.D.

Source: ASAM Patient Placement Criteria for th e Treatment of Substance- Related Disorders,

(Second Edition -– Revised ): (ASAM PPC-2R) April, 2001.

Methods of Funding Services

• ADAA provides funding for services through grants and contracts to private and non-profit providers and local health departments. Most dollars are allocated to local health departments that either provide services directly or contract with community-based provider organizations.

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Allocation of Funds• 24 Local Jurisdictional Grant Awards for Prevention,

Treatment and Recovery Support Services (SAPT Block Grant and General Funds, 111.1 million)

• Supplemental grants to jurisdictions for Recovery SupportServices, including Recovery Housing

– Funded and implemented Care Coordination in each jurisdiction beginning January 2012

• Operational Costs• Transfer of Dollars to MA for PAC Expansion• Statewide Residential Contracts

- Pregnant Women and Women with Children

- Criminal Justice Patients

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Sources of Funding– Federal Grants

• Substance Abuse Prevention and Treatment Block Grant

• Maryland’s Strategic Prevention Framework (MSPF)• Access to Recovery (ATR)• Tobacco Enforcement

– General State Funds– Special Funds

• VLT’s Licensing fee

– Reimbursable Funds

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25

ReimbursableFunds$6.2M3.93%

Special Funds$24.8M15.66%

Federal Funds$39.7M25.07%

General Funds $87.7M55.34%

ADAA Fiscal 2013 Budget

The fiscal 2013 budget for the ADAA is $158,488,051

Budget Changes for 2013

26

• $5.2 million in new general funds for Recovery and Housing services

• Transfer of $16.1 million in general funds to Medical Assistance Primary Adult Care (PAC) to fund substance use disorder treatment (increase of $6.765 million from FY 2012)

27

Grants and contracts comprise the majority of ADAA’s spending, with these expenditures supporting substance use disorder treatment and prevention services. Salary expenditures support 68.5 full-time equivalent positions and 6.77 contractual positions.

ADAA Fiscal 2013 Expenditure Categories

Salaries$5,250,1563.31%

MA/PAC$16,139,26110.17%

Grants andContracts$137,059,45786.35

%

Other$264,1710.17%

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People Served by Funding from the Alcohol and Drug Abuse Administration

29

Individual Patients, Admissions and Enrollments in State-Supported Substance Use Disorder Treatment ProgramsFY 2008 to FY 2013

46,75849,701

52,91155,384 55,451

52,388

40,116 41,51943,758 45,088 45,158

42,426

32,627 33,834 35,049 35,986 35,63433,354

FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013

Individuals

Admissions

Enrollments

46,75849,701

52,911

55,384 55,451

40,116 41,51943,758

45,088 45,158

52,388

42,426

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Patient Age at Admission to State-Supported Substance Use DisorderTreatment Programs

FY 2013

Under 18

18 - 20

21 - 25

26 - 30

31 - 40

41 - 50 Over 50

9.7%

7.5%

16.3%14.3%

18.4%

21.2% 12.6%

N = 43,525

31

White Males25.7%

Hispanic Males1.7%

Black Males24.2%

Other Males0.9%

White Females28.1%

Hispanic Females1.2%

Black Females17.6%

Other Females0.6%

White Males35.4%Hispanic Males

4.0%

Black Males28.5%

Other Males1.5% White Females

19.1%

Hispanic Females1.0%

Black Females10.0%

Other Females0.5%

MH Services Received

N = 23,595

No MH Services Received

N = 60,970

32

Health Coverage* of Admissions to State-Supported Substance Use Disorder Treatment ProgramsFY 2008 to FY 2013

FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 20130

10

20

30

40

50Thousands

None

HealthChoice/Medicaid

Primary Adult Care (PAC)

Other Public Funds

Private Insurance

18.0%15.6%

17.4%18.4% 17.8%

17.2%

6.4%7.9% 8.9%

7.4% 7.8%7.6%

6.7% 12.3% 15.5%18.5%

14.9%16.9%

20.3%

23.6%25.2%

25.0%60.7% 59.6%

46.7%

38.4%33.7% 31.7%

*Not necessarily supporting the substance use disorder treatment

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Source of Referral to State-Supported Substance Use Disorder Treatment Programs FY 2013

Other Criminal Justice

DWI

Probation/Parole

Juvenile Justice

Drug Court

Prison/Jail

Self-Referral

Parent/Family

SUD Tx Provider

Other Health-Care

DSS/TCA

School

Other Community

8.2%5.7%

12.5%

4.4%

4.0%

1.9%

30.2%

2.4%

9.7%

7.7%

2.5%1.9%

8.7%

N = 43,431

34

ASAM Level of Care for Enrollments in State-Supported Substance Use Disorder Treatment Programs

FY 2013

Level 0.5

Level I

Level I.D/II.D

Level II.1

Level II.5

Level III.1

Level III.3

Level III.5

Level III.7

Level III.7.D

OMT

3.5%

36.7%

0.3%

17.9%

3.5%

2.2%2.7%

2.1%

13.9%9.6%

7.6%

N = 53,667

35

Leading Primary-Substance Problems for Admissions to State-Supported Substance Use Disorder Treatment Programs

FY 2008 to FY 2012

FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013

0

2

4

6

8

10

12

14

16Thousands

Alcohol

Heroin

Marijuana

Rx Opioids

Cocaine

36

Pattern of Substance Abuse Problems among Admissions to State-Supported Substance Use Disorder Treatment Programs

FY 2013

Note: Up to three substance problems may be reported for each admission.

Alcohol Only

Alcohol & 1 Drug

Alcohol & 2 Drugs

One Drug Only

Two Drugs

Three Drugs

16.5%

17.9%

15.3%

22.9%

16.3%

11.1%

N = 43,522

37

Alcohol

Crack Cocaine

Other Cocaine

Marijuana

Heroin

Benzodiazepines

Oxycodone

Other Rx Opioids

PCP

Other

29.0%

5.9%

1.6%

21.4%

28.4%

1.1%

7.3%

3.0%1.0%

1.2%

38

Heroin-Related Admissions* to State-Supported Substance Use Disorder Treatment ProgramsPrimary Route of Administration by Race and Age

2013

14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76

Age at Admission

0

100

200

300

400

500

White Injectors

Black Injectors

White Inhalers

Black Inhalers

*Up to three substance problems may be reported for each admission.

39

43.3

56.7

62.4

37.6

29.6%

70.4%

55.9%

44.1%

1

2

Mental-Health Problem

None IndicatedWhite Males White Females

Black Males Black Females

40

Reason for Discharge from State-Supported Substance Use Disorder Treatment Programs FY 2013

Completed Treatment

Completed/Referred

Other Referral

Incarcerated

Non-Compliance

Patient Left

Health/Death

20.2%

25.0%

10.2%

3.0%

7.5%

33.0%

1.1%

N = 39,669

41

Median and Mean Length of Stay (Days) for Dis-Enrollments from State-Supported Substance Use Disorder Treatment Programs

FY 2013

65.9

123.3

12.0

68.5

25.4

99.0

100.6

98.1

18.2

7.0

378.6

50.0

99.0

5.0

49.0

13.0

83.0

71.0

103.0

15.0

6.0

174.0

Level 0.5

Level I

Level I.D/II.D

Level II.1

Level II.5

Level III.1

Level III.3

Level III.5

Level III.7

Level III.7.D

OMT

0.0 100.0 200.0 300.0 400.0

Median

Mean

42

Adolescent and Adult Substance Use, Tobacco Use, Employment, Arrest and Homelessness Percentage Outcomes

Discharges from State-Supported Substance Use Disorder Treatment Programs2013

Note: Discharges from detoxification and short-term residential treatment are excluded.

7 2.5

%

7 2.3

%

3 1.9

%

7 0.1

%

6 .1%

2 5.6

%

8 .8%

8 .2%

4%

4 3.7

%

4 4.4

%

2 1.7

%

5 0.8

%

8%

3 4%

6%

4 .9%

3.1%

Adolescents Adults Adolescents Adults Adolescents Adults Adolescents Adults Adolescents Adults

0%

20%

40%

60%

80%

Admission

Discharge

-39.8% -38.5%

-32.1%

-27.5%

+31.3%

+32.7%

-31.8% -40.9%

-22.3%

Used Substances in Past 30 Days

Used Tobacco in Past 30 Days

Employed Full or Part-Time

Arrested in Past 30 Days

Homeless

43

Mental-HealthTreatment Received* during Substance Use Disorder Treatment Episode by Patients Discharged from State-Supported

Substance Use Disorder Treatment ProgramsFY 2013

48.5%

51.5%

18.1%

81.9%

No Mental-Health Problem at Admission

IndicatedN = 22,298

Mental-Health Problem at AdmissionN = 17,371

Yes

Yes

No

No

*Either within or outside the SUD treatment program

44

Primary Source of Payment for Discharges from State-Supported Substance Use Disorder Treatment ProgramsFY 2008 to FY 2013

52.5 51.644.8

36.8 33.6 32.0

10.5 12.3

15.2

19.721.2 22.7

0 .00 .0

3.4 10.8 13.3 15.4

11.6 12.6 10.67.9 7.6 6.6

10.1 9.4 10.6 12.0 12.6 11.9

12.0 10.8 11.7 10.2 9.0 9.6

3.3 3.3 3.7 2.5 2.6 1.9

FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 20130.0%

20.0%

40.0%

60.0%

80.0%

100.0%

State Grant

HealthChoice/Medicaid

Primary Adult Care (PAC)

Other Public Funds

Private Insurance

Out-of-Pocket

Other

52.5 51.6

45

Characteristics and Service UsageAlcohol and Drug Abuse Administration

Mental Hygiene AdministrationConsumers in Common

Ages 15 and overFiscal Year 2013 Data Sets

46

Consumers in PMHS, ADAA, and Both

PMHS ADAA Both -

20,000

40,000

60,000

80,000

100,000

120,000 110,790

51,139

12,688

47

Consumers in PMHS, ADAA, and BothConsumers in PMHS, ADAA, and Both

Male Female0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

41.3%

58.7%

66.4%

33.6%

53.6%

46.4%

Comparison by Gender

PMHS ADAA Both

Afr. Amer. White Other0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

47.2% 49.1%

3.7%

44.9%

51.2%

3.9%

46.5%50.7%

2.8%

Comparison by Race

PMHS Only ADAA Only Both

48

Consumers in PMHS, ADAA, and Both

16 to 25 26 to 40 41 to 54 55 to 64 65 and over0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

30% 31%28%

10%

2%

29%34%

30%

7%1%

22%

37% 36%

6%0%

Comparison by Age

PMHS ADAA Both

49

Consumers in PMHS, ADAA, and Both

Never Married Married/Living as couple Sep/Div/Widowed0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

76.6%

9.5%13.9%

67.5%

12.9%

19.6%

68.3%

9.0%

22.7%

Comparison by Marital Status

PMHS ADAA Both