When the Hawaii Department of Human Services began moving its Medicaid program to managed care from fee-for-service in 1994, it recognized that an entire class of mentally ill patients could be at risk of falling through the cracks.
Its challenge was daunting: how to treat in a managed-care setting some 500 severely mentally ill Medicaid recipients spread over six Hawaiian islands separated by hundreds of miles.
"No one had ever tried to assemble this kind of broad-based behavioral health program in Hawaii before," says Carolyn Gire, program director for Community Care Services and director of contracted programs for the Hawaii Medical Service Association, the state's Blue Cross and Blue Shield plan. "We brought in as many people with experience working with the seriously mentally ill as we could, and we sought a lot of input. (DHS officials) knew that behavioral health services were so specialized they had to put those patients together."
In November of that year, a time Gire says "is engraved in all our minds," Community Care Services was formed. CCS is a joint venture between the HMSA, the state's largest health insurance company; Hawaii Biodyne, a subsidiary of Magellan Behavioral Health, the state's only behavioral managed-care company; and Hawaiian psychiatrist Tom Leland, M.D., CCS medical director.
The HMSA is the at-risk contractor responsible for fiscal oversight. Hawaii Biodyne provides clinical management, human resources, information management and network development; and CCS provides the direct care, oversight of care coordination and utilization management.
The program brings together community providers, advocacy groups and patients from different islands.
Gire says the program's goal is to work with beneficiaries to maintain their independence and self-respect. CCS attempts to accomplish that through focused, individualized care coordination, patient advocacy and placement of patients into the least-restrictive care settings.
CCS conducted a study of 120 patients enrolled throughout the three-year pilot program and found the total per-member, per-year costs dropped $232, or 5.4%, from 1995 to 1997. Overall costs for services that were most intensive and restrictive-such as 24-hour care (inpatient hospitalization and crisis care) and emergency and professional services-dropped, while costs for care in the least expensive and restrictive settings, such as psycho-social rehabilitation, day care and care coordination, increased.
"By corralling these people with special needs into one program, it allows us to specialize," she says. "Most of our risk management is done through intensive case management. By knowing our members well and working with their special needs, we can try and reduce the likelihood of them (losing control) and requiring hospitalization. We've reduced hospitalization quite significantly, more than 60%."
And Gire points out that CCS has no pending lawsuits.
"There are whole quarters when we have had no complaints," she says.
Henry "Hank" Goldstein, who serves as executive director for both the HMSA and CCS, says CCS leaders listen to their advisory board, which includes members of advocacy and consumer groups.
"It's important to involve people in the process, so we don't lose touch," Goldstein says.
Treating a special-needs population scattered over hundreds of miles and isolated on some islands lacking services presents a unique challenge, he says, noting that transportation is an issue for most patients.
"And we definitely have a homeless and addiction component here," he says. "Many of these people would get lost if left to their own devices. We know where they hang out and get them hooked up with the care they need."
Goldstein says patient responsiveness has improved, as have patients' relationships with their care coordinators. "The crux of the program is thinking outside of the box, developing broad continuums of care and developing relationships with all stakeholders and patients."