Missouri tries capitated payment system for children with behavioral health needs
Children troubled by behavior and psychological problems rarely are served by a seamless public/private continuum of care. "Bounced" is the word most commonly used to describe how they move between programs.
Missouri state officials are kicking off a program designed to change that.
The program in eastern and central Missouri integrates the financing and delivery of community and home-based services for children with severe behavioral health needs. For a capitated rate of $3,199 per child per month, a care management organization will assume responsibility for services the children now receive through six different divisions of state government.
The targets for the project are the most severely disturbed of the 96,000 Missouri children in out-of-home residential settings. An estimated 15% of these children consume about 85% of the services provided to this population by the Departments of Mental Health and Social Services.
"These are children with very complex needs across multiple systems," says project director Lisa Clements, PhD. "Our attempt is to increase the opportunity for children to live in their own home and communities."
Officials are extremely cautious in implementing the Missouri Interdepartmental Initiative for Children with Severe Needs. No more than 10 children per month will be enrolled, and the program will be capped at 1,000 participants.
"It’s a slow roll-out," acknowledges Ms. Clements. "We really want to assure that the community-based system necessary to serve these children actually is developed."
About 60% of Missouri’s children live in one of the initiative’s two regions, the first encompassing St. Louis and four surrounding counties and the second comprising 17 counties in the central part of the state. While Medicaid eligibility does not affect a child’s enrollment in the initiative, the project boundaries coincide with those of Missouri’s Medicaid managed care rollout, thus facilitating coordination between the two programs. Regions in the initiative cross the boundaries of the state’s service delivery system but do follow the boundaries of Missouri’s judicial circuits.
Children eligible for the program must live in one of the target counties, have serious behavioral health needs, and be at risk of out-of-home placement. The eligible age ranges from 4 through 21, although services will not be initiated after a child’s 18th birthday. The decision regarding which children are routed to the project is made by interdisciplinary "interagency teams."
State divisions chip in funds
Money for the program comes on a pro rata basis from each of the state divisions serving emotionally disturbed children: mental health, comprehensive psychiatric services, mental retardation and developmental disabilities, and alcohol and drug abuse. Ms. Clements realizes that the project has yet to prove itself and confront some of the agencies’ natural protectiveness toward their clients.
"It’s sort of a wait-and-see," she says. "Though the commitments have been made and the departments certainly have been quite supportive, the verdict is still out on how the system responds to children and families represented by various stakeholders."
The capitation rate is set to make the project budget-neutral, although state officials assumed that the site of services would shift dramatically from out-of-home residential settings to less intensive settings, including a child’s family home.
State officials have contracted for care management with the Missouri Alliance for Children and Families, a for-profit limited liability corporation created in July 1998 by 10 community and residential care providers throughout the state. The alliance is responsible for organizing the network of providers and hiring care managers—Ms. Clements calls them the "backbone" of the system—to direct the delivery of services. The 40-month care management contract allows for four months of planning and 36 months of service delivery.
When the request for care management proposals was released in mid-1998, the alliance was the only respondent. Although state officials were able to negotiate successfully with the alliance, they are hoping for a more competitive process when they release another request for proposals to increase the capacity of the project at some future time. State officials haven’t ruled out helping with the development of additional care management organizations.
"We don’t know if they’re just not developed or because of something else. We don’t really know what the issues are," says Ms. Clements.
"We think there are different care management organizations with different provider networks with different areas of expertise," she says. "We want to make those options available to the interagency teams when they make the referrals in and to families to actually choose them."
Contact Ms. Clements at (573) 751-8215.
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