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From HARPs to DSRIP to VBP:
Promise or Peril?
Evolving Strategies for the Delivery
and Payment of Mental Services
MHA Regional Policy Council
February 19, 2016
Harvey Rosenthal NYAPRS Executive director
1
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.
[email protected]
www.nyaprs.org
2
Impact of a Broken System
 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
Impact of a Broken System
 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
Elements of a Broken System
 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
Affordable Care Act:
National Healthcare Reform
The Triple Aim: improving outcomes,
improving quality, reducing cost
Key features: expansion of Medicaid
and managed care, behavioral health
parity, home and community based
services including self-directed care
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Affordable Care Act
State Healthcare Reform
 Focus on
 Coordination
 Integrated physical and behavioral healthcare
 Outcomes
 Prevention
 Wellness
 Hospital diversion
 Individualized care
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New York State’s Challenge
 $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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NYS Medicaid Waiver
 Health and Recovery Plans
 Health Homes
 Home and Community Based Services
 Delivery System Reform Incentive Payment
 Performing Provider Systems
 Value Based Payment
 Eliminate racial disparities in healthcare
The Mantras of the MRT
From fee for service to outcome based
care
Diversion from emergency room and
inpatient hospital use
Surprise! We are healthcare providers
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NYS Medicaid Redesign
 Managed Care for All
 Universal Access to High Quality Primary
Care; Integrate physical and BH services
 Targeting the Social Determinants of Health
 Health Homes: Teams of providers working
together to coordinate care for Medicaid
consumers who use lots of services
Managed Care Plans Now
Offer Medicaid funded BH Services
 Inpatient - SUD and MH

 Clinic – SUD and MH
 Personalized Recovery

Oriented Services

 Assertive Community
Treatment

 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
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)
15
Health Plans in Broome County
Aetna
Capital District Physicians Health
Plan
Excellus Health Plan.
Fidelis Care New York
MVP Health Care
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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
What are your experiences with
Health Home Care Management?
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NYS Health Home Model
Managed Care Organizations (MCOs)
New York State Designated Lead Health Home
Administrative Services, Network Management, Health IT Support/Data
Exchange
Health Home Care Management Network
Partners (includes former Total Care Management
Providers)
Medicaid
Analytics
Performa
nce
Portal
(MAPP)
Comprehensive Care Management
Care Coordination and Health Promotion
Comprehensive Transitional Care
Individual and Family Support
Referral to Community and Social Support
Services
Use of Health Information Technology to
Link Services (Electronic Care Management
Regional
Health
Informati
on
Organizati
ons
(RHIOs)
Records)
Access to Required Primary and Specialty Services
(Coordinated with MCO)
Physical Health, Behavioral Health, Substance Use Disorder
Services, HIV/AIDS, Housing, Social Services and Supports
October 23, 2015
Catholic Charities of Broome County
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Greater Binghamton Health Center
Endwell Family Physicians
The Family & Children's Society
Catholic Charities Of Broome County
The Addiction Center Of Broome County
Southern Tier Independence Center
Mental Health Association Of Southern Tier
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Catholic Charities of Broome County
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Broome County Mental Health Department
Our Lady of Lourdes Memorial
Greater Binghamton Health Center
Conifer Park
Samaritan Counseling Center Of The Southern Tier
LB Prescription Enterprises
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Catholic Charities of Broome County
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United Cerebral Palsy Association of NYS
Broome County Health Department
Broome County Mental Health
Community Options
United Health Services Hospital
Greater Binghamton Health Center
NYS Office Of Mental Health
United Health Services Hospitals
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United Health Services
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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
Conifer Park
United Health Services
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United Health Services
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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
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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
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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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NYS Home and Community Based Services Option
Medicaid Will Now Pay for:
Rehabilitation
Psychosocial Rehabilitation
Community Psychiatric Support
and Treatment (CPST)
Residential Supports/Supported
Housing
Habilitation
Crisis Intervention
Short-Term Crisis Respite
Intensive Crisis Intervention
Mobil Crisis Intervention
Educational Support Services
Support Services
Family Support and Training
Non- Medical Transportation
Individual Employment Support
Services
Prevocational
Transitional Employment Support
Intensive Supported Employment
On-going Supported Employment
Peer and Family Supports
Self Directed Services
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
NYS Medicaid Redesign Response:
Managed Integrated BH & Medical Care
OASAS
Health and Recovery
Plan (HARP)
Health
Home
Team
= Physical and/or
behavioral health
care provider
STATE MEDICAID
AGENCY DOH
Health and
Recovery Plan
(HARP)
Payers
Health Home
Team: Provider
Network
OMH
Health and Recovery
Plan (HARP)
Health
Home
Team
Health
Home
Team
29
NYS Medicaid Waiver
$7.1 billion over 5 years for DSRIP
$650 million to play for Home and
Community Based Services
30
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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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
October 23, 2015
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
11
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
3.a.iv
4.a.iii
Strengthen Mental Health and Substance Abuse Infrastructure across
1
October 23, 2015
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
34
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
35
Provider Groups
 Hospitals
 Vocational Rehabilitation
 Services for People w Developmental
Disabilities
 Health Homes
 Compeer
 Pharmacies
36
Provider Groups
 Hospice and Palliative Care
 Therapeutic Communities
 Senior Living Center
 Suicide Prevention And Crisis Service
 United Cerebral Palsy Association
 Visiting Nurse Service
 YMCA
37
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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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
39
Projects
 Integrated Delivery System
 Development of Community Based
Health Navigation Services
 Patient Activation
 Evidence-Based Strategies for Disease
Management
 COPD Preventative Care and
Management
40
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
41
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
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
43
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
44
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.
45
Value-Based Propositions
 Proposals to:
 Integrate physical and behavioral healthcare
 get ahead of relapse and readmissions and
support crisis stabilization
 promote mental, emotional and behavioral
(MEB) well-being in communities;
prevention and strengthening MH/SA
infrastructure across system
46
Value-Based Propositions
An example
 NYAPRS proposed 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
NYAPRS has successfully applied this model within a
managed care contract to reduce hospital use by 48% and
Medicaid spend by 47%
47
NYAPRS Advocacy on Value Based
Payment Work Groups
 We helped see that OMH HCBS services were
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
 We’ve pushed for the state to provide
infrastructure dollars and technical assistance
for community based providers
48
NYAPRS Advocacy on Value Based
Payment Work Groups
 We’ve insisted that VBP outcomes
include recovery and social determinant
related ones (beyond HEDIS)
 Ex: maintenance of housing stability
 Strong emphasis on cultural
competence
 Buy not Build
 Position our members for gain sharing
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NYAPRS VBP Advocacy:
Advocacy and Engagement
 Development of 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
50
Homework
 NYAPRS and MHANYS: partnerships that
advocate for recovery outcomes, services and
providers and for consumer rights and choice
protections
 Our 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
51
Homework
 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’
 Assume responsibility for health literacy,
improved wellness self management and
health outcomes
52