Transcript NYS Medicaid Redesign: How to Transform a State Health

NYS Medicaid Redesign: How to
Transform a State Health and
Behavioral Health System Overnight
Harvey Rosenthal NYAPRS
Philip Saperia CBHA
John Copolla ASAPNYS
NJAMHAA Annual Conference
April 13, 2016
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New York Association of Psychiatric
Rehabilitation Services (NYAPRS)
A peer-led statewide coalition of people who
use and/or provide community mental health
recovery services and peer supports that is
dedicated to improving services, social
conditions and policies for people with
psychiatric disabilities by promoting their
recovery, rehabilitation, rights and community
integration and inclusion.
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New York Association of Psychiatric
Rehabilitation Services (NYAPRS)
Advocacy
Training & Technical Assistance
Peer Service Innovations
Employment & Economic Self-Sufficiency
Cultural Competence
Medicaid Redesign Team, Behavioral Health Work
Group, Value Based Payment Steering Committee
[email protected]
www.nyaprs.org
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Coalition for Behavioral Health Agencies
As the umbrella advocacy organization of
behavioral health agencies in New York City and
environs, the Coalition’s mission is to advocate
for, inform, and provide training and technical
assistance for these agencies so that they may
provide the best possible services with
sufficient funding in a favorable regulatory
environment.
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Coalition for Behavioral Health Agencies
Taken together, these agencies serve
more than 350,000 adults and children
and deliver the entire continuum of
behavioral health care in every
neighborhood.
MRT Behavioral Health Work Group
http://www.coalitionny.org/
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Coalition for Behavioral Health Agencies
 Advocacy
 Communications
 Research and Information
 Learning and Technical Assistance
 Collaborative Decision Making
 System Change Promotion (Center for
Rehabilitation and Recovery)
 Fighting Stigma
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Alcoholism and Substance Abuse
Providers of New York State
 ASAP is committed to working together to
support organizations, groups and individuals
that prevent and alleviate the profound
personal, social and economic consequences
of alcoholism and substance abuse in New
York State.
 ASAP represents the interests of the largest
alcoholism and substance abuse prevention,
treatment, research and training providers in
the country.
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Alcoholism and Substance Abuse
Providers of New York State
ASAP is committed to working together
to support organizations, groups and
individuals that prevent and alleviate the
profound personal, social and economic
consequences of alcoholism and
substance use disorders in NYS.
http://www.asapnys.org/
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Alcoholism and Substance Abuse
Providers of New York State
 Advocacy & Representation in Albany
and Washington
 Networking
 Immediate access to industry breaking
news
 Conferences and Training Opportunities
MRT Behavioral Health Work Group
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Change is not Optional
 Very high health, social and criminal
justice costs with very low outcomes
 Early mortality: cardiovascular,
respiratory and infectious diseases,
diabetes and hypertension
 Highest rates of avoidable readmissions
 High rates of violence victimization,
incarceration, homelessness and suicide
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Change is not Optional
 High rates of poverty:
unemployment and idleness
Stigma and discrimination: isolation
 Loss of hope, purpose, dignity
 Magnified exponentially for
communities of color and other
underserved groups
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Change is not Optional
 Fragmented, Siloed and Uncoordinated
 Unresponsive: Reactive vs Preventive and
Diversionary
 Unaccountable: who can we turn to?
 Wrong Incentives: volume over value
 Illness over Wellness? Wellness over Illness?
 ‘Chronic’ Patienthood over Personhood
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New York State’s Challenge (2011)
 $54 billion Medicaid program with 5 million beneficiaries
 20% (1 million beneficiaries) use 80% of these dollars:
hospital, emergency room, medications, longtime
“chronic” services
o Over 40% with behavioral health conditions
 20% of those discharged from general hospital BH units
are readmitted within 30 days: NYS avoidable Medicaid
hospital readmissions: $800 million to $1 billion annually
 70% with behavioral health conditions; 3/5 of these
admissions for medical reasons
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Some MRT Mantras
From fee for service to outcome based
care
Diversion from emergency room and
inpatient hospital use
Surprise! We are healthcare providers
Buy or Build?
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Starting Assumptions
 Waste and inefficiencies in the system
 Winners and losers (not all boats get
lifted)
 Intellectual and administrative
bandwidth to manage VBP
 Quality of care will actually be improved
Arthur Webb Group
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The Carve-in: Managed Care Plans Now
Offer Medicaid funded BH Services
 Inpatient - SUD and MH
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 Clinic – SUD and MH
 Personalized Recovery
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Oriented Services
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 Assertive Community
Treatment
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 Partial Hospitalization
 Comprehensive Psychiatric
Emergency Program
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Targeted Case
Management
Opioid treatment
Outpatient chemical
dependence rehabilitation
Rehabilitation supports for
Community Residences
(phased in in 2016)
Health and Recovery Plans
• Designed for people with more extensive
mental health and/or substance use related
conditions
• Covers all benefits provided by Medicaid
Managed Care Plans, including expanded
behavioral health benefits
• Also provides additional Home and Community
Based Services to help people live better, go to
school, work and be part of the community
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Who’s Eligible for a HARP?
 SSI Recipient
 ACT, TCM, PROS, PMHP in past year
 30+ days of psych hospitalization, 3+
admissions or 3+ month stays in OMH
housing over the past 3 years
 60+ days in OMH psych center
 Incarceration w BH treatment past 4 years
 2+ SUD ER visits, detox stays for SU related
inpatient stays
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Who’s Not Eligible for HARPs?
 Have both Medicaid and Medicare
 Live in a nursing home
 Are in a Managed Long Term Care Plan
 Are under age 21
 Have services from the Office for People with
Developmental Disabilities (OPWDD)
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Health Plans in Broome County
Aetna
 Capital District Physicians Health
Plan
 Excellus Health Plan.
 Fidelis Care New York
 MVP Health Care
$2,500 PMPM
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HARP Beneficiaries’ Care is
Managed via Health Homes
 Health homes are ‘a home for your healthcare”
 Everyone gets a care coordinator who conducts an
assessment and works with each individual to develop
their own goal and service plan which are intended to be
shared electronically with all providers and social services
that support them
 Health home responsibilities include:
 Active engagement
 24-7 response
 Focus on well coordinated discharge and treatment
planning
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Health Homes
Advantages for Providers
• To Get Connected to the Future
• Part of an Integrated Care Team
• Access to Referrals
• Electronic Data Sharing
• Outcome Focused and Accountable
• Positioned for Managed Care: Health Homes are
Organizing Networks Which Will Contract with MC
Companies
• Behavioral Health Providers Bring Vital Services to
Networks
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Health Homes
Advantages for Beneficiaries
• Integrated Care
• Help with Navigating the Health Care
System
 Better Access
 Better Coordination
• Wellness and Person Centered
• Skills to Stay Healthy
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NYS Home and Community Based Services Option:
Medicaid Will Now Pay for
(Post Health Home Assessment: )
Rehabilitation
Support Services
Family Support and Training
Non- Medical Transportation
Psychosocial Rehabilitation
Community Psychiatric Support
and Treatment (CPST)
Residential Supports/Supported
Housing
Individual Employment Support
Services
Habilitation
Crisis Intervention
Prevocational
Transitional Employment Support
Intensive Supported Employment
On-going Supported Employment
Short-Term Crisis Respite
Intensive Crisis Intervention
Mobil Crisis Intervention
Peer and Family Supports
Self Directed Services
Educational Support Services
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NYS Medicaid Redesign Response:
Managed Integrated BH & Medical Care
OASAS
Health and Recovery
Plan (HARP)
with a BHO
Health
Home
Team
= Physical and/or
behavioral health
care provider,
including HCBS
STATE MEDICAID
AGENCY DOH
Health and
Recovery Plan
(HARP)
Health Home
Team: Provider
Network
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OMH
Health and Recovery
Plan (HARP)
with a BHO
Health
Home
Team
Health
Home
Team
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United Health Services
Southern Tier Health Home
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Arms Acres
Conifer Park
Greater Binghamton Health Center
Arms Acres
Southern Tier AIDS Program
United Health Services
The Family and Children's Society
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United Health Services
Southern Tier Health Home
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Broome County Mental Health Department
Volunteers Of America
YMCA
Twin Tier Home Health
Binghamton Housing Authority
Broome County Council Of Churches
Broome County Department Of Social Services
Broome County Lift
Broome County Office For The Aging
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United Health Services
Southern Tier Health Home
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CASA
Community Hunger Outreach Warehouse
Mental Health Association Of Southern Tier
Professional Home Care
Addictions Center Of Broome County
Alcoholics Anonymous
American Cancer Society
Fairview Recovery Services
Holliswood Hospital
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United Health Services
Southern Tier Health Home
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Mothers And Babies Perinatal Association
Narcotics Anonymous
Opportunities For Broome
Rehabilitation Support Services
Retired And Senior Volunteer Program
Salvation Army
Serafini Transportation Corporation
SOS Shelter
Southern Tier Healthlink
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Beyond HEDIS Outcome Measures
7 days from inpatient discharge
to outpatient appointment
30 days to filled prescription
Depression screening and
follow up
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HCBS Outcome Measures:
Social Determinants of Care
 Participation in employment
 Enrollment in vocational rehabilitation
services and education/training
 Improved or Stable Housing status
 Access to and use of Peer Support
 Longer Community tenure, Decreased
Hospital Readmissions
 Decreased Criminal justice involvement
 Improvements in functional status
 Cultural & Linguistic Competence,
Engagement
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What impacts health outcomes?
Behavioral
Patterns
40%
Social
Circumstances
15%
Health Care
10% Environmenta
l Exposure
5%
Genetic
Predisposition
30%
Source: Schroeder, Steven A. We Can Do Better – Improving the Health of the American
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People. N Engl J Med 2007;357:1221-8
Outcome Data is Key
 Full addiction treatment coverage could result in $398
savings per-member per-month (PMPM) in Medicaid
spending
 Medical costs were $311 lower PMPM than for people
who needed but did not receive treatment
 Treatment > 60 days can save $8,200 in
healthcare/productivity
 Likelihood of being arrested decreased 16%; likelihood
of felony conviction dropped by 34%
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Outcome Data is Key
 Individuals in MAT use half of the health care
resources; pregnant women had shorter hospital
stays for addiction treatment (10 days vs. 17.5 days)
 MAT was associated with fewer inpatient admissions
for alcohol dependence cases, and the total health
care costs were 30% less
 Medical costs decreased by 33% for Medicaid patients
over three years following their engagement in
treatment
Becky Vaughn VP of Addictions
National Council for Behavioral Health
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NYS Medicaid Waiver
 $7.1 billion over 5 years for DSRIP
 $650 million to play for Home and
Community Based Services
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Delivery System Reform Incentive
Payment Program (DSRIP)
 Promotes community-level collaborations that
improve the quality and outcomes of care, while
achieving a 25% reduction in avoidable hospital
use from 2015-20.
 Safety net providers are expected to collaborate
to implement innovative projects focusing on
system transformation and population health
improvement.
 All DSRIP funds will be based on performance
linked to achievement of project milestones.
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Giving DSRIP Funds to Hospitals….
to Keep People out of Hospitals?!
Reinventions
 DSRIP leads
 Urgent Care Centers
 Buying primary care practices
 Building or buying community
behavioral health services?
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25 Performing Provider Systems
 Performing Provider Systems are
networks of providers that
collaborate to implement DSRIP
projects
 Each PPS must include providers to
form an entire continuum of care
 Hospitals
 Health Homes
 Skilled Nursing Facilities (SNF)
 Clinics & FQHCs
 Behavioral Health Providers
 Home Care Agencies
 Other Key Stakeholders
Community health care
needs assessment based on
multi-stakeholder input and
objective data
Building and
implementing a DSRIP
Project Plan based upon
the needs assessment in
alignment with DSRIP
strategies
Meeting and Reporting on
DSRIP Project Plan process
and outcome milestones
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Key Mental Health Projects in DSRIP
Project Description
PPSs
Involved
3.a.i
Integration of primary care and behavioral health services
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3.a.ii
Behavioral health community crisis stabilization services
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3.a.iii
Implementation of Evidence-Based Medication Adherence Program
(MAP) in Community Based Sites for Behavioral Health Medication
Compliance
2
Development of Withdrawal Management (e.g. ambulatory
detoxification, ancillary withdrawal services) capabilities and appropriate
enhanced abstinence services within community-based addiction
treatment programs
4
3.a.v
Behavioral Interventions Paradigm (BIP) in Nursing Homes
1
4.a.i
Promote mental, emotional and behavioral (MEB) well-being in
communities
2
4.a.ii
Prevent Substance Abuse and other Mental Emotional Behavioral
Disorders
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1
4.a.iii
Strengthen Mental Health and Substance Abuse Infrastructure across
3.a.iv
Behavioral Health Projects
 Integration of primary care and behavioral
health services (required of all 25 PPSs)
16 PPSs also included:
 Community crisis stabilization services
 Transitional Supports
 Activation
 Medication adherence programs
 Withdrawal Management
 Behavioral Interventions in Nursing Homes
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Care Compass Network
 Also known as: Southern Tier Rural Integrated
Performing Provider System, Inc., STRIPPS,
United Health Services Hospitals, Inc.
 Counties served: Broome, Chemung,
Chenango, Cortland, Delaware, Schuyler,
Steuben, Tioga, Tompkins
 Attribution for Performance:
102,386
 Total Award Dollars:
$224,540,275
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Projects
 Integrated Delivery System
 Development of Community Based
Health Navigation Services
 Patient Activation
 Evidence-Based Strategies for Disease
Management
 COPD Preventative Care and
Management
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Projects
 30 Day Care Transitions for Chronic
Diseases, including BH Conditions
 Integration of Behavioral Health and
Primary Care
 Strengthen Mental Health and
Substance Abuse Infrastructure,
Prevention and Targeted Interventions
 Crisis Stabilization
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Provider Groups
 Home Care
 Independent Living Center
 Addiction Center
 Nursing and Rehabilitation Center
 Primary Care
 County Health Departments
 County Office for Aging
 Hospice and Palliative Care
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Provider Groups
 Hospitals
 Vocational Rehabilitation
 Services for People w Developmental
Disabilities
 Health Homes
 Compeer
 Pharmacies
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Provider Groups
 Hospice and Palliative Care
 Therapeutic Communities
 Senior Living Center
 Suicide Prevention And Crisis Service
 United Cerebral Palsy Association
 Visiting Nurse Service
 YMCA
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Behavioral Health Providers
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Lakeview Mental Health Services,
Liberty Resources
Mental Health Association of the Southern Tier
Northeast Parent and Child Society
Onondaga Case Management Services
Parsons Child And Family Center
Phoenix Houses
Planned Parenthood
Rehabilitation Support Services
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Value Based Payment
 What are Value Based Payments (VBPs)?
An approach to Medicaid reimbursement
that rewards value over volume
Incentivizes providers through shared
savings and financial risk
 Directly ties payment to providers with
quality of care and health outcomes
A component of DSRIP that is key to the
sustainability of the Program
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Value-Based Payment Reform
 Required to ensure ‘long term sustainability
of DSRIP investments”
 By waiver Year 5 (2019), all MCOs must
employ non-fee-for-service payment
systems that reward value over volume for
at least 80-90% of their provider payments
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Value-Based Payment Reform
 Required to ensure that “value-destroying
care patterns” (avoidable admissions, ED
visits, etc) do not simply return when the
DSRIP funding stops in 2020
 If VBP goals are not met, overall DSRIP
dollars from CMS to NYS will be
significantly reduced
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Accountability and Risk Go Together
>80% by end of DSRIP Year 5
>25% by end of DSRIP Year 5
Level 0
Level 1
Level 2
Level 3
Provider Financial Risk
Partial
Capitation
Pay for
Performance
(P4P)
Bundled/
Episodic
Payments
Upside
Shared
Savings
Two Way
Shared
Savings
Incentive
Payments
Fee For
Service
Provider Integration and Accountability
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Full
Capitation
VBP: Sharing in the Savings
 To share in savings, you eventually need to
take on risk…
 Partnering with other providers is essential to
being able to take on risk
 We need to join forces with other providers to
have enough cash reserves to take on Level 2
risk, which applies 90% of the savings to
reward effective providers.
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Value-Based Propositions
An example
 NYAPRS proposes to provide peer bridger services aimed
at helping people with ‘serious’ mental health and
addiction related conditions to:
 Reduce avoidable emergency room and inpatient visits by 40%
 Increased self-management and participation with chosen
medications, services and supports
 Stages: Outreach & Engagement, Crisis Stabilization,
Wellness Self Management, Community Connections
 NYAPRS has successfully applied this model within a
managed care contract to reduce hospital use by 48% and
Medicaid spend by 47%
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Value Based Payment Work Groups
some final recommendations
 OMH HCBS services added to the list of SDH
interventions
 All Level 2 and 3 plans or providers must
address at least one social determinant and
contract with at least 1 CBO
 NYS must provide infrastructure dollars and
technical assistance for community based
providers
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Value Based Payment Work Groups
some final recommendations
 VBP outcomes should include recovery
and social determinant related ones
 Strong emphasis on cultural
competence
 Buy not Build
 Position our members for gain sharing
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Value Based Payment Work Groups
some final recommendations
 Uncapped Member Incentive Programs
 Creation of an Expert Group for Achieving
Cultural Competence in Incentive Programs
 Use of Patient Reported Outcomes (PRO)
 Expansion of ombuds program
 Plan for how best to communicate VBP to
consumers/members
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VBP Implications for Providers
 Goal: Overall improvement in health and well being
 Care management: Engage, control, process
 Data warehouse: Know the people you serve and
capture the information
 Quality: know your value
 Cost: Dig into the cost of delivery—small margin
world
 Risk: Understand your tolerance level
 Tools: Build them—IT, clinical measurement
 Collaborate!
Arthur Webb Group
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Partnerships
 With each other
 Health Homes
 With PPSs
 MCOs
 FQHCs
 Primary Care Providers
 IPAs
 MSOs
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In Five Years From Now…
 More people will be served
 Getting a better bang for the buck
 There will be pain
 Fewer providers
 Major consolidation across the spectrum
 Membership in major networks
 Safety net support will be a must
Arthur Webb Group
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MRT Resources
 Transitional funding: Start up, HIT,
Capital Infrastructure
 Managed Care Technical Assistance
Center
 https://www.health.ny.gov/health_care/
medicaid/redesign/: webinars,
whiteboards, reports
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Homework
 CBHA, ASAP, NYAPRS: Advocacy, Education, TA
 Member agencies: attain good positioning in
health home and DSRIP networks, offer relevant
and reliable value propositions, raise level of
infrastructure (contracting, billing, compliances)
and workforce
 Recovering people: be prepared to make
informed choices!; New health home assessment,
plan and selection of recovery and HCBS services;
use of self-directed care dollars and ‘patient
incentives’
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