Prepared by

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