Estimated Staff Time Effort, Costs, and Medicaid Revenues for Coordinated Specialty Care Clinics Serving Clients With First-Episode Psychosis

The New York State OnTrackNY program was first implemented in 2013 and provides coordinated specialty care to youths and young adult New York State residents who are within 2 years of the onset of nonaffective psychosis (4, 5). As of 2018, 21 teams were operating throughout New York State, serving 696 clients. In addition to providing routine clinic services, such as medication management and individual and group psychotherapy, OnTrackNY programs provide education, employment, and family support along with assertive outreach, peer support, and psychosocial rehabilitation services. New York State had received approval from the Centers for Medicare and Medicaid Services to allow Medicaid reimbursement for these “home- and community-based services” for high-need clients, and at the time of this study, the state was developing procedures to include clients with first-episode psychosis as an eligible population. The team-based model also includes significant case management and staff consultation activities that do not have an established funding mechanism.

The study team randomly selected 78 clients from a list of all Medicaid clients enrolled in 13 sites providing coordinated specialty care during an identified 2-week period in June 2017. The 13 sites were chosen because they had been in operation for more than 12 months, thereby limiting the impact of clinic start-up activities on the time study data. Medicaid-enrolled clients were selected because they accounted for 51% of all clients served in the programs and because the study team had access to New York State Medicaid billing codes to estimate revenues. The study team used a stratified random selection procedure to identify six clients from each site: two each in the early phase of care (enrolled in the coordinated specialty care clinic less than 4 months), intermediate phase (enrolled for 5–8 months), and extended phase (enrolled for at least 9 months). If a site did not have two Medicaid clients in each of the three phases, clients from other phases were sampled to reach the total of six clients. Three sites had only five Medicaid clients enrolled in care (all phases combined) during the identified period, leaving a final total sample of 75 clients.

Each site was given a daily activity log template to document all activities provided to each identified client during the 2-week study period. Clinic staff members were instructed to document all billable and nonbillable activities for the identified clients including care and case management and administrative activities (e.g., supervision, case conferences, and record keeping). Each site’s program director reviewed the daily logs for accuracy and entered the data into a client activity record. Data from the daily activity logs and client activity records were imported into a database that included the clinic site name and each client’s age, service dates, credentials of staff person completing each activity, time spent on each activity, location and whether the activity was conducted face to face with the client, a brief service or activity description, and a Current Procedural Terminology (CPT) or home- and community-based service code if the clinic was billing or thought it could have billed for that activity.

Staff members from the 13 clinics reported a total of 528 specific activities completed for the 75 selected clients during the 2-week study period. The study team determined that staff activities could be grouped into four categories: Medicaid state plan reimbursable services (e.g., medication management, individual and group psychotherapy); activities reimbursable under the state’s Medicaid waiver for home-and community-based services, including peer, family, educational, and employment support; care and case management, including outreach and telephone coordination with enrolled clients, family, and outside treatment providers (these activities are reimbursable in New York State only for clinics designated as Health Home care management agencies, which did not include any of the OnTrackNY clinics); and administrative activities that are not reimbursable, such as staff supervision, case conferences, and medical record documentation.

Two members of the study team independently reviewed and assigned each activity to one of the four categories. All CPT codes provided by the teams were reviewed and confirmed or changed to ensure that the database would estimate revenues with optimal billing (codes were assigned according to the highest reimbursement rate that could be justified based on the activity described). Add-ons and quality adjustments available in the state’s Medicaid program were also applied wherever applicable. A client mix factor was used to estimate monthly time allocations and Medicaid revenue generated for each team. The client mix factor was meant to account for the distribution of each team’s total caseload of Medicaid clients across the three phases of care (early, intermediate, and extended). Average costs to operate a clinic team were obtained from budgets submitted from the first seven sites opened under the state’s OnTrackNY initiative, all of which participated in the time study. These seven original sites were required to submit budgets comprising full operational costs of the program (similar data were not available from the other six sites).