蜜柚直播

But hard data that could help illuminate how patients are faring has been hard to come by.

When Cenpatico Integrated Care took over management of the Southern 蜜柚直播 behavioral-health system in 2015, the insurer promised data-driven accountability in its new role as the regional behavioral-health authority for Pima County and seven other counties.

Three-and-a-half-years later, the insurer 鈥� now known as 蜜柚直播 Complete Health 鈥� has released little patient-outcome data that could shed light on how its members with behavioral-health needs have fared since it took charge.

Data obtained by the 蜜柚直播 shows trends since 2015 that are worrisome to some 蜜柚直播 providers and advocates.

Among the concerns:

• An increase in mental-health transports by 蜜柚直播 police.
• More petitions for court-ordered mental-health evaluations, to determine if a person is a danger to one鈥檚 self or others and requires court-ordered treatment.
• And a rise in inpatient psychiatric hospital days for patients with mental illness at at least one large behavioral-health agency.

With many factors at play, including an ongoing opioid crisis, it鈥檚 impossible to nail down a single cause of increased reliance on 蜜柚直播 crisis services. And greater utilization of the Crisis Response Center could be a positive trend, as awareness of the CRC as an alternative to jail continues to grow among law enforcement.

But mental-health advocates say years of Cenpatico鈥檚 payment cuts, evolving payment structures and ever-changing demands on behavioral-health agencies are undermining coordination of care for vulnerable patients in Southern 蜜柚直播.

Clarke Romans, executive director of the National Alliance on Mental Illness Southern 蜜柚直播, or NAMI, said there鈥檚 been too little data released publicly 鈥� by both 蜜柚直播鈥檚 Medicaid agency AHCCCS and 蜜柚直播 Complete Health 鈥� to show what taxpayer dollars are paying for.

AHCCCS payments to 蜜柚直播 Complete Health totaled more than $726 million in the fiscal year that ended in September 2018, compared to $685 million the year prior, .

鈥淭here鈥檚 no accountability,鈥� Romans said. 鈥淭here鈥檚 just a giant cloud of mystery around how are people actually being served.鈥�

DATA OBTAINED BY THE STAR

The Star requested patient hospitalization data from three of the biggest behavioral-health agencies in 蜜柚直播: La Frontera 蜜柚直播, COPE Community Services and CODAC. CODAC declined to share data with the Star. Rod Cook, CEO of COPE Community Services, said the agency鈥檚 data wasn鈥檛 consistent enough to ensure an apples-to-apples comparison between Cenpatico versus the previous regional behavioral-health authority, which was the nonprofit 蜜柚直播-based Community Partnership of Southern 蜜柚直播.

A Star analysis of data shared by La Frontera found the number of psychiatric hospitalization days per 1,000 patients has been trending upwards since fiscal year 2013, and the growth accelerated after fiscal year 2016.

In fiscal year 2012, the number of hospital days per 1,000 La Frontera patients was 561, compared to 1,169 in fiscal year 2018, which ended in September. La Frontera had about 6,500 enrolled members that year.

In response to a public-records request, the 蜜柚直播 Police Department released data showing mental-health transports to the Crisis Response Center or psychiatric hospitals increased from 2,224 in 2013 鈥� the earliest reliable data-year 鈥� to 3,366 in 2018.

The crisis center, which opened in 2011, has been a boon for law enforcement agents, who used to have to spend hours waiting at a hospital for a patient in crisis to be received.

Now, they can drop someone off at the center and are received within 10 minutes, said Pima County Sheriff鈥檚 Department Sgt. Sean Payne, supervisor of the mental-health support team.

A March data-trends report from the Pima County Behavioral Health department shows the monthly average number of petitions for court-ordered evaluations increased from 147 in fiscal year 2016 to a monthly average of 178 in fiscal year 2018.

But Paula Perrera, department director, emphasized that the figures represent a small subset of the behavioral-health population, and she said it鈥檚 hard to draw any broader conclusions from the limited dataset.

鈥淭here鈥檚 so many variables in the system. I don鈥檛 think we have a good enough handle on all of the data that we are in a position to opine,鈥� Perrera said.

For Romans of NAMI Southern 蜜柚直播, the increase makes sense. He鈥檚 hearing more from people with mental illness, or their family members, that patients are being hospitalized or court-ordered repeatedly, in some cases after being discharged while they were still symptomatic and unstable.

鈥淲ithin a very short time, they鈥檙e either petitioned (for court-ordered treatment) again or re-hospitalized,鈥� he said. 鈥淚t鈥檚 just like this treadmill sort of thing that these individuals can鈥檛 seem to get out of.鈥�

Ongoing turmoil

Through its contract with AHCCCS, nonprofit Community Partnership of Southern 蜜柚直播 managed the behavioral-health system in Pima County for two decades before, in 2015, it lost its contract to Cenpatico Integrated Care, a subsidiary of publicly traded insurance giant Centene, based in St. Louis. (Cenpatico changed its name to 蜜柚直播 Complete Health, effective in October.)

Since the for-profit insurer entered the market, 蜜柚直播 behavioral-health agencies facing lower reimbursements have laid off hundreds of staff and some have merged with larger providers.

A chaotic October 2018 transition to integrated medical and behavioral-health care for patients enrolled in the state鈥檚 Medicaid program 鈥� the 蜜柚直播 Health Care Cost Containment System, known as AHCCCS 鈥� resulted in millions of dollars in unpaid claims, putting small, niche providers at risk of closure.

Under the new integrated care structure, Cenpatico 鈥� now 蜜柚直播 Complete Health 鈥� is one of three insurers in Southern 蜜柚直播 providing coverage that includes both physical and behavioral-health care. The other two Southern 蜜柚直播 integrated health plans are Banner-University Family Care and United Healthcare Community Plan. (Those with a designation of 鈥渟erious mental illness,鈥� as well as other groups like children in foster care, are still covered under the regional behavioral-health authority system.)

Turmoil over the past few years has hindered access to routine care for patients, who are more likely to spiral into crisis and require hospitalization if they are unable to reach a case manager, reschedule an appointment in a timely manner or get their medications refilled, said Romans of NAMI .

鈥淭here鈥檚 just all kinds of little barriers that, for this set of patients, are big barriers,鈥� Romans said.

The behavioral-health system has been strained in recent years, in part because management of how services are utilized has become less intensive, since that responsibility now falls to the insurers rather than front-line providers, said Dan Ranieri, CEO of La Frontera 蜜柚直播, one of the largest providers of behavioral-health care and affordable housing in the region.

鈥淵ou鈥檙e seeing a lot of (inpatient) services inflate,鈥� he said. 鈥淲e certainly don鈥檛 have any substantial data related to patient outcomes to know whether it鈥檚 a good thing or a bad thing. But we do know the system is more financially stressed than it鈥檚 been in 20 years.鈥�

Recently, agencies have scaled back case-management services which, as of October, are no longer covered by default for patients with behavioral-health needs. Some behavioral-health agency leaders say that鈥檚 a reasonable change, as case management services aren鈥檛 necessary for every member.

But others say the loss of case managers is causing problems. Smaller programs are trying to fill that role when possible, helping members find stable housing, apply for food stamps or find transportation services, but they are not paid for that work, program leaders say.

鈥淲e find ourselves doing it without being reimbursed for it, because people need it in order to be successful in a job,鈥� said Dot Kret, founder of 蜜柚直播 agency DKA, which offers free job training and coaching to people with disabilities or barriers to employment.

She鈥檚 noticed anxiety levels rising among clients with mental illness who no longer have their own case manager.

鈥淧eople are forced into crisis situations that might not have occurred otherwise,鈥� she said. 鈥淲hen people don鈥檛 have somebody to go to and they try to figure it out on their own, the frustration increases, the depression increases, the anxiety increases.鈥�

AHCCCS AND CENPATICO: NO INTERVIEWS

On Jan. 31, the Star requested an interview with Jami Snyder, the new director of AHCCCS, to discuss the behavioral-health system in Southern 蜜柚直播. After canceling a scheduled March 22 interview, an agency spokeswoman said Snyder had no time for a phone interview.

The Star requested any data AHCCCS has collected that could show how patients have fared in Southern 蜜柚直播 since Cenpatico entered the market. AHCCCS spokeswoman Heidi Capriotti directed the Star to an AHCCCS webpage containing quality data reports, but the data that tracked patient outcomes over time used combined data from across the state; no measures were specific to Southern 蜜柚直播 and Cenpatico.

Capriotti also directed the Star to an to integrated medical- and behavioral-health-care coverage for certain Medicaid populations, including those with a designation of 鈥渟erious mental illness.鈥� But this report, released in November 2018, studied only those with serious mental illness in Maricopa County.

On March 6, the Star requested an interview with 蜜柚直播 Complete Health CEO James Stover. Spokeswoman Monica Coury said Stover had no time for an interview.

ACCOUNTABILITY AND DATA

During Cenpatico鈥檚 first contract year, which began in fall 2015, then-CEO Terry Stevens emphasized the importance of tracking providers鈥� data to show how patients are doing.

After a February 2016 interview with Stevens, the Star reported that 鈥淐enpatico wants detailed reports on health outcomes for patients as part of its data-driven accountability system. It has been tracking the 20 percent of patients who have the most severe behavioral-health needs to ensure they鈥檙e getting treatment. The (regional behavioral-health authority) is pushing for improvement in specific performance measures, such as reducing patients鈥� emergency room visits ... and it鈥檚 focusing on reducing repeat hospitalizations and recidivism among people with mental illness who serve jail time.鈥�

In response to a Star inquiry seeking any data that would show how patients have fared in these or other measures since Cenpatico came to town, company spokeswoman Monica Coury released a four-page document that cited mostly short-term tracking of specific patient populations, such as those with serious mental illness who also have chronic obstructive pulmonary disease.

Between the first and last quarter of fiscal year 2018, those patients were 57 percent less likely to utilize the emergency department following a 鈥渢eam-based approach to disease management,鈥� the document said.

Coury did not respond to follow-up questions seeking an interview about the data and requesting raw numbers to show how many patients were involved in the pulmonary disease study.

Coury鈥檚 document also cited a six-month, 72-person pilot project, in partnership with peer-run behavioral-health agency Hope Inc. and Sonora Behavioral Health Hospital, aimed at reducing hospital readmissions.

Hope is run by 鈥減eers,鈥� those who have personally engaged with the behavioral-health system or have a family member who has. In the pilot, peer staffers worked closely with hospitalized patients after discharge to provide support and help reconnect them with outpatient services.

鈥淚t鈥檚 not rocket science; it鈥檚 just showing somebody that you care,鈥� said Dan Haley, CEO of Hope. 鈥淭hat makes such a huge difference and that鈥檚 why peer support is so effective.鈥�

Seventy percent of the participating patients did not experience a readmission between October 2018 and January, which was the first half of the pilot. Data from the second half isn鈥檛 available yet, Haley said.

Close coordination between behavioral-health agencies and local hospitals used to be the norm, but that鈥檚 changed in recent years, said Cook of COPE Community Services. COPE used to have caseworkers meet their patients at the hospital, or at the Crisis Response Center, working to get them back into the community, with an eye toward long-term stabilization, he said.

But today, patients are no longer assigned to an agency that acts as a 鈥渉ealth home鈥� 鈥� they can go to whatever providers they want, resulting in more freedom of choice, but far less coordination of care. Now providers sometimes don鈥檛 even know what other services their members are receiving, Cook said.

And provider agencies are now reimbursed using a fee-for-service model, in which payments are based on the volume of services provided. Until recently, agencies got an upfront monthly payment per patient. That gave providers an incentive to closely manage members鈥� care and avoid intensive services like hospitals and instead help patients access more effective, and cheaper, wraparound outpatient services, Cook said.

鈥淵ou鈥檙e looking for the most cost-effective and clinically appropriate place for them,鈥� he said. 鈥淚t鈥檚 almost never the hospital.鈥�

Constant changes in payment structures under Cenpatico have challenged agencies鈥� ability to plan financially and provide services efficiently, said Susie Huhn, executive director of provider agency Casa de los Ni帽os.

鈥淭hey kept changing the financial models every year, which really was hard on providers because then you have to change your practice model,鈥� she said. 鈥淎nd you can鈥檛 change practice models in a year and have good outcomes.鈥�

CRISIS RESPONSE CENTER

蜜柚直播 has a strong crisis network, including a nurse-triage crisis line, the Crisis Response Center and mobile crisis teams run by agencies like Community Bridges, said psychiatrist Margie Balfour, chief of quality and clinical innovation for Connections AZ, which contracted with Banner-University Medical Center in 2014 to take over management of the CRC.

Since 2015, the Crisis Response Center has seen a 7.7 percent increase in adult visits and a 24 percent increase in youth visits.

鈥淭he question is, is it a good thing or is it a bad thing? The answer is kind of both,鈥� Balfour said. 鈥淢aybe some people aren鈥檛 doing well, are not getting their needs met鈥� and go into crisis, she said. 鈥淏ut some of it is also the police becoming more comfortable and informed and skilled in engaging people and bringing them to treatment, instead of to jail.鈥�

Ranieri of La Frontera 蜜柚直播 said it makes sense that CRC visits are rising as awareness grows, but he said another factor is providers having fewer opportunities to head off crises before they occur.

鈥淚n the past, the interventions in the field were more likely to happen and people would never get to the CRC,鈥� he said. 鈥淚 don鈥檛 think people are going to the CRC inappropriately. I just think a lot of the aggressive interventions that might have gone on in the past just aren鈥檛 happening nowadays, for a host of reasons.鈥�

Crisis services are a 鈥済ap-filler,鈥� filling in when patients either aren鈥檛 connected with services at all, perhaps because they鈥檙e new in town, or helping patients who can鈥檛 reach their case manager or are having trouble getting their medication, Balfour said.

Addressing basic needs holistically, including safe and decent housing, is a fundamental service that crisis centers can鈥檛 address on their own, she said.

鈥淵ou鈥檝e got someone who鈥檚 depressed, suicidal, but they鈥檙e homeless,鈥� Balfour said. 鈥淚鈥檇 be depressed and suicidal if I was homeless. ... People having a safe place to live is probably the thing we struggle the most with that鈥檚 out of our control, and that鈥檚 across the country.鈥�

Sgt. Jason Winsky, supervisor of TPD鈥檚 mental-health support team, said well-functioning crisis services are critical, but too few people are asking questions about the more routine outpatient services that can help people avoid a crisis in the first place. Media reports often focus on the initial crisis response, he said.

鈥淭here鈥檚 never media asking about, 鈥榃ell, what about two months after the crisis? How is that person doing?鈥欌�� he said. 鈥淚t鈥檚 not the CRC鈥檚 job to make a 90-day plan for somebody.鈥�

For Alexei Ruiz, 24, a stint in the Crisis Response Center was unhelpful. Ruiz grew up in the foster-care system, bouncing between foster homes and group homes, experiencing physical and sexual abuse. Ruiz, who has diagnoses of PTSD, panic disorder and bipolar disorder, said a series of difficult events last year became too much to bear, including the end of an abusive relationship, a manic episode and a near-eviction.

Ruiz, who prefers the pronoun 鈥渢hey鈥� instead of 鈥渉e鈥� or 鈥渟he,鈥� said their needs were dismissed at the CRC because they were so much quieter than the other patients. Ruiz stayed there two days under observation, but said everyone there seemed apathetic.

鈥淚 was hoping to get someone to talk to me so I didn鈥檛 feel like I was so out of control,鈥� Ruiz said. 鈥淏ut I didn鈥檛. I got slapped with, 鈥榊ou鈥檙e fine,鈥� and I took the bus home.鈥�

Soon after, Ruiz was connected with a caseworker named Sam, and the caseworker鈥檚 compassion helped get Ruiz to stability. For about six months, Ruiz felt that someone understood what they had been through and understood their triggers.

鈥淪he was so involved in my life. She genuinely cared,鈥� Ruiz said.

Growing up in foster care, Ruiz said, it was common to tell one鈥檚 entire life story to a caseworker, getting retraumatized through the process, and then having to do it all again a month later with a new caseworker, due to high turnover rates in the child-welfare system.

A couple of months ago, it felt like d茅j脿 vu when Ruiz called to confirm an appointment and learned that Sam had been laid off.

鈥淢y support system was completely cut off,鈥� Ruiz said.

THE 鈥淢ERRY-GO-ROUND鈥�

For families with loved ones experiencing mental illness or psychosis, trying to navigate the behavioral-health system feels like 鈥渁 merry-go-round,鈥� said 蜜柚直播 mom Louise Rempfer, a NAMI advocate for people with mental illness. She said her 28-year-old son has been struggling with mental-health issues since experiencing a psychotic break in 2012, when he was living in California. He has been diagnosed with schizoaffective disorder.

Short-term stints in the CRC or psychiatric hospitals seem unending, and the stays rarely result in stability for any real length of time, she said.

鈥淚t鈥檚 just cyclical,鈥� she said. She feels like there鈥檚 little coordination between his care providers and little respect for his family鈥檚 input: It recently took her almost nine months to get her son鈥檚 doctor to agree that he needed a medication change.

鈥淚 have to figure out ways to help him that are more resourceful than what the behavioral-health system鈥檚 offering,鈥� she said. 鈥淲e鈥檙e not getting to the root of this.鈥�

Rempfer said in retrospect, her son was probably depressed as a child. She said he was always kind and gentle, working three jobs as a teenager: grocery store bagger, lifeguard and kids鈥� karate instructor. He鈥檚 creative and energetic, and it鈥檚 heartbreaking to watch him be traumatized over and over with each crisis, she said.

The bigger-picture problem in behavioral-health care is that the system is too focused on treating surface-level symptoms, rather than addressing patients鈥� root challenges or trauma, Romans said. Early, wraparound intervention as soon as symptoms emerge would be key to improving crucial health metrics, like the dramatically reduced life expectancy for people with serious mental illness, he said.

鈥淲e are dealing with the symptoms of underlying illnesses,鈥� he said. 鈥淲hy don鈥檛 we spend the money up front, and actually we would save money, improve quality of life and life expectancy? What a concept.鈥�