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Serving the Criminal Justice Population: Reentry & Community Health Programs
Medicaid Health Plans of America, National Conference
November 12, 2015 Steven Rosenberg
Proprietary Companies and Justice Involved Individuals: October 2015 Developments
• “[Molina HealthCare] has agreed to acquire Providence Human Services, LLC, and Providence Community Services, LLC, both wholly owned subsidiaries of the Providence Service Corporation.” For more information on PCC and its practices: http://www.nytimes.com/2015/10/02/us/private-probation-company-accused-of-abuses-in-tennessee.html
• “Corrections Corporation of America [CCA] now also touts itself as the largest domestic owner of community corrections beds after buying Oklahoma-based halfway house operator Avalon Correctional Services… … In September, CCA also bought properties occupied by four community corrections facilities in Pennsylvania for about $13.5 million.” Source: http://www.tennessean.com/story/money/real-estate/2015/10/29/cca-deal-boosts-investment-half-way-houses/71674910/
2 September 2013
Probation 3.9 Parole
0.9
Jail 0.7
Prison 1.5
U.S. Correctional Populations Single-Day Snapshot 2012
(millions)
September 2013 3
11.6
2.2
Jail Prison
Year-Long Snapshot (millions)
Who is involved in the criminal justice system?
3
Health Status of Justice-Involved Individuals
• Justice-involved individuals are disproportionately young, male, persons of color, and poor.
• They have high rates of health problems (chronic and infectious disease, injuries), psychiatric disorders, and substance use disorders (SUDs).
• 80% of individuals in jail with chronic medical conditions have not received treatment in the community prior to arrest.
4 September 2013
Health Status of Justice-Involved Individuals
• Jails have become de facto behavioral health providers in many communities: – Mental Health Problem: 64% of jail inmates. – Serious Mental Illness: 15% for men and 31% for
women. – Co-occurring Substance Use Disorder: 72% of men
and 75% of women.
5 September 2013
Health Status of Justice-Involved Individuals
• 60-80% of arrestees tested positive for at least one illegal substance.
• Fewer than 10% of arrestees at 8 of the 10 sites reported receiving outpatient substance use or alcohol treatment in the prior year.
• 13-38% of arrestees tested positive for multiple substances.
• 13-30% of arrestees said they had been arrested two or more times in the prior year.
The ADAM II 2011 Report
6 September 2013
Disparities in Criminal Justice: The Pipeline to Prison
Source: The Community Coalition
7 September 2013
Most Individuals in Jail Return to the Community
• Nationally, only about 4% of jail admissions result in sentences to prison.
Or, in other terms...
• 96% of jail detainees and inmates return directly to the community from jail, often along with their existing health conditions.
8 September 2013
The Same Frequent Fliers:
Most expensive health care users are also the most likely to be incarcerated • Rikers Island - 400 Frequent Flyers
– 10,000 jail stays; 300,000 jail days in five years – 67% have mental health needs – 99% percent report SUDs – 85% of charges were misdemeanors or violations
9 September 2013
0
50
100
150
200
250
300
Children PregnantWomen
WorkingParents
JoblessParents
ChildlessAdults
Perc
enta
ge F
PL
Source: The Kaiser Family Foundation and the Georgetown University Center for Children and Families, 2012
Medicaid Eligibility, pre-ACA
Prior to ACA, justice-involved population largely unserved.
• Less than 10% of those released from jail had access to insurance
10 September 2013
What does this mean for health plans’ seeking to serve this population in re-entry?
• Two Strategies
– Risk Corridors – Reach-In Efforts
11 September 2013
Risk Corridors
• Increased Capitation Rate for Justice-Involved Individuals
• Twice as likely as general public to be admitted to hospital within first seven, 30, and 90 days following release
0.00%1.00%2.00%3.00%4.00%5.00%6.00%7.00%8.00%9.00%
ReturningPop
GeneralPop
7 Days30 Days90 Days
Source: Wang et. al, 2013, JAMA
12 September 2013
Reach-In Efforts
• Center for Medicare and Medicaid Innovation (CMMI) Grants
• Transitions Clinic Network
• Treatment Alternatives for Safe Communities
13 September 2013
But, we do not know how to treat people with primary diagnosis of SUD
• Very little data on primary SUD
• People in jails have huge rates of primary SUD
14 September 2013
Simply Enrolling Individuals in Medicaid is not Enough
• Ohio mandates Medicaid enrollment upon
entering jail • Bureaucratic timing issues means that an
individual has probably relapsed or had another run in with the law before his Medicaid benefits kick in
15 September 2013
What if we focus more on pre-entry?
Law Enforcement Assisted Diversion (LEAD)
0%
20%
40%
60%
80%
100%
LEADGroup
ControlGroup
Pre-EvaluationPostEvaluation
0%5%
10%15%20%25%30%35%40%45%
LEADGroup
ControlGroup
Pre-EvaluationPost-Evaluation
% with nonwarrant-related arrest % charged with felony
Source: University of Washington Evaluation, March 2015
16 September 2013
Challenges to focus on diversion
• Lack of Connectivity
• Lack of Data about What Works
• Cannot Develop Risk Corridors or Reach-In Strategies
• Lack of Behavioral Health Resources
17 September 2013
Opportunities: New Funding and New Technology
• New population that is covered by federal regulations
opens new funding streams for plans
• Health IT allows for connectivity and behavioral health monitoring
• Focus on behavioral health creating new resources (i.e., Excellence Act)
18 September 2013
Plans should focus on both re-entry and pre-entry
• Develop business systems to coordinate with criminal
justice system
• Integrate behavioral and physical health services
• Coordinate with public safety to develop pre-entry diversion programs
• Hire and train culturally competent practitioners
19 September 2013
New Opportunity: The Excellence Act (2014)
• Creates Certified Community Behavioral Health Clinics (CCBHCs) designed to improve mental health and substance use disorder treatment with many requirements, including:
– Care Coordination – Mobile crisis mental health services – Screening, assessment, and diagnosis – Targeted case management – Peer support and counselor services – Psychiatric rehabilitation services
20 September 2013
New Opportunity: 1115 Waiver
• Waiver to allow justice-involved individuals continuing access to Medicaid through: – Allowing states and counties to identify patients in county jails
and maintain their treatment protocols – Allowing Medicaid providers to work with county jails to develop
treatment and continuity of care plans – Allowing states and counties to initiate medically necessary care
and intervention for jailed individuals with opiate addictions. – Allowing states and counties to reimburse peer counselors
21 September 2013
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