CO Medicaid Mental Health Quality & Network Adequacy, Olmstead, & Contracting: Known Knowns, Known Unknowns, and Unknown Unknowns

      I think sometimes why Olmstead is so resisted by States is that it provides a dictate -- BUT it doesn't provide a lot in HOW.  
                The U.S. Supreme Court's decision was really designed to give the States flexibility.   It has taken awhile since the original 1999 Olmstead Case to work some of this out.
              The Minnesota Federal Olmstead Planning Case, the Georgia/DOJ MI/DD Comprehensive Settlement Agreement, the Delaware/DOJ Findings Letter re: NO Fundamental Alteration where bringing Housing & Services to Scale, DOJ Guidance on Olmstead-- at the end of the  day there was a lot to be gleaned from those.
                          Then States like Colorado promptly ignored all that stuff -- also, known as LAW. 
                           So it's a little bit,  maybe a lot Pollyannish to say, "If the States just had the right tools, they would do the right thing."
                          BUT the States are doing some right things in Colorado and around the country -- they've even got some good things in their provider contracts -- although, not NEAR ENOUGH.
                              States spend A LOT MORE TIME on contracting with providers than they do with Olmstead Planning. 

             With Olmstead Planning -- often States just don't do Olmstead Planning at all or there are no MEASURABLE GOALS, etc. even though its pretty much common knowledge that the States have NOT brought Housing & Services to Scale to prevent unnecessary institutionalization of people with disabilities, including the great risk of institutionalization in homelessness.

                   BUT the Code of Federal Regulations & CMS have some "requirements" -- some softer than others -- regarding:

• Managed  Care Quality Assessment &
•  Improvement

                          One of the challenges to one's sanity is that we already have some pretty important known values::

• Thousands of people with mental illness in Colorado Jails.
• Thousands of people with mental illness in Colorado Prisons.
• Thousands of People with mental illness who are Homeless.
• Thousands of People with mental illness who are in nursing homes.
• Federal Legal Duties on States to provide Housing & Services for People with Disabilities to avoid unnecessary institutionalization, or the great risk of institutionalization inherent in homelessness OR Provide a Comprehensive, Effectively Working Plan to do so with Measurable Goals, Etc..
• Federal Legal Duties on States to Provide Mental Health Parity, including modifying CAPITATION RATE SETTING where necessary.
• It is Medicaid Mental Health Managed Care that needs to have "NETWORK ADEQUACY" to provide for the people listed above in the Community. NEWS FLASH:  COLORADO MEDICAID DOES NOT HAVE "NETWORK ADEQUACY" FOR THIS.
• The State has made some improvements, BUT what it is doing is WAY NOT ENOUGH to comply with the LAW and even more importantly save Coloradans with mental illness from the  Horrors of Abuse or Neglect or the Daily rights violations that have been and are occurring.

42 CFR § 438.330 Quality assessment and performance improvement program.

(a)   General rules.

(1) The State must require, through its contracts, that each MCO, PIHP, and PAHP establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees that includes the elements identified in paragraph (b) of this section.

(2) After consulting with States and other stakeholders and providing public notice and opportunity to comment, CMS may specify performance measures and PIPs, which must be included in the standard measures identified and PIPs required by the State in accordance with paragraphs (c) and (d) of this section. A State may request an exemption from including the performance measures or PIPs established under paragraph (a)(2) of this section, by submitting a written request to CMS explaining the basis for such request.

(3) The State must require, through its contracts, that each PCCM entity described in § 438.310(c)(2) establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees which incorporates, at a minimum, paragraphs (b)(2) and (3) of this section and the performance measures identified by the State per paragraph (c) of this section.

(b) Basic elements of quality assessment and performance improvement programs. The comprehensive quality assessment and performance improvement program described in paragraph (a) of this section must include at least the following elements:

(1) Performance improvement projects in accordance with paragraph (d) of this section.

(2) Collection and submission of performance measurement data in accordance with paragraph (c) of this section.

(3) Mechanisms to detect both underutilization and overutilization of services.

(4) Mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs, as defined by the State in the quality strategy under § 438.340.

(5) For MCOs, PIHPs, or PAHPs providing long-term services and supports:

(i) Mechanisms to assess the quality and appropriateness of care furnished to enrollees using long-term services and supports, including assessment of care between care settings and a comparison of services and supports received with those set forth in the enrollee's treatment/service plan, if applicable; and

(ii) Participate in efforts by the State to prevent, detect, and remediate critical incidents (consistent with assuring beneficiary health and welfare per §§ 441.302 and 441.730(a) of this chapter) that are based, at a minimum, on the requirements on the State for home and community-based waiver programs per § 441.302(h) of this chapter.

(c) Performance measurement. The State must -
(1)

(i) Identify standard performance measures, including those performance measures that may be specified by CMS under paragraph (a)(2) of this section, relating to the performance of MCOs, PIHPs, and PAHPs; and

(ii) In addition to the measures specified in paragraph (c)(1)(i) of this section, in the case of an MCO,PIHP, or PAHP providing long-term services and supports, identify standard performance measures relating to quality of life, rebalancing, and community integration activities for individuals receiving long-term services and supports.

(2) Require that each MCO, PIHP, and PAHP annually -
(i) Measure and report to the State on its performance, using the standard measures required by theState in paragraph (c)(1) of this section;

(ii) Submit to the State data, specified by the State, which enables the State to calculate the MCO's,PIHP's, or PAHP's performance using the standard measures identified by the State under paragraph (c)(1) of this section; or

(iii) Perform a combination of the activities described in paragraphs (c)(2)(i) and (ii) of this section.

(d)Performance improvement projects.

(1) The State must require that MCOs, PIHPs, and PAHPs conduct performance improvement projects, including any performance improvement projects required by CMS in accordance with paragraph (a)(2) of this section, that focus on both clinical and nonclinical areas.

(2) Each performance improvement project must be designed to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction, and must include the following elements:

(i) Measurement of performance using objective quality indicators.

(ii) Implementation of interventions to achieve improvement in the access to and quality of care.

(iii) Evaluation of the effectiveness of the interventions based on the performance measures inparagraph (d)(2)(i) of this section.

(iv) Planning and initiation of activities for increasing or sustaining improvement.

(3) The State must require each MCO, PIHP, and PAHP to report the status and results of each project conducted per paragraph (d)(1) of this section to the State as requested, but not less than once per year.

(4) The State may permit an MCO, PIHP, or PAHP exclusively serving dual eligibles to substitute an MA Organization quality improvement project conducted under § 422.152(d) of this chapter for one or more of the performance improvement projects otherwise required under this section.

(e) Program review by the State.

(1) The State must review, at least annually, the impact and effectiveness of the quality assessment and performance improvement program of each MCO, PIHP, PAHP, and PCCM entity described in § 438.310(c)(2). The review must include -

(i) The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required to report.

(ii) The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement projects.

(iii) The results of any efforts by the MCO, PIHP, or PAHP to support community integration for enrolleesusing long-term services and supports.
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(2) The State may require that an MCO, PIHP, PAHP, or PCCM entity described in § 438.310(c)(2) develop a process to evaluate the impact and effectiveness of its own quality assessment and performance improvement program.

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