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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 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. 2 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 3 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. 4 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/ 5 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 6 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. 7 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/ 8 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 9 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 10 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 11 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 12 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 13 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? 14 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 15 16 The Carve-in: 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 17 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 18 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 19 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) 20 Health Plans in Broome County Aetna Capital District Physicians Health Plan Excellus Health Plan. Fidelis Care New York MVP Health Care $2,500 PMPM 21 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 22 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 23 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 24 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 25 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 26 OMH Health and Recovery Plan (HARP) with a BHO Health Home Team Health Home Team 26 United Health Services Southern Tier Health Home Arms Acres Conifer Park Greater Binghamton Health Center Arms Acres Southern Tier AIDS Program United Health Services The Family and Children's Society 27 United Health Services Southern Tier Health Home 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 28 United Health Services Southern Tier Health Home 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 29 United Health Services Southern Tier Health Home 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 30 Beyond HEDIS Outcome Measures 7 days from inpatient discharge to outpatient appointment 30 days to filled prescription Depression screening and follow up 31 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 32 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 33 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% 34 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 35 NYS Medicaid Waiver $7.1 billion over 5 years for DSRIP $650 million to play for Home and Community Based Services 36 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. 37 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? 38 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 39 Key Mental Health Projects in DSRIP Project Description PPSs Involved 3.a.i Integration of primary care and behavioral health services 25 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 40 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 41 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 42 Projects Integrated Delivery System Development of Community Based Health Navigation Services Patient Activation Evidence-Based Strategies for Disease Management COPD Preventative Care and Management 43 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 44 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 45 Provider Groups Hospitals Vocational Rehabilitation Services for People w Developmental Disabilities Health Homes Compeer Pharmacies 46 Provider Groups Hospice and Palliative Care Therapeutic Communities Senior Living Center Suicide Prevention And Crisis Service United Cerebral Palsy Association Visiting Nurse Service YMCA 47 Behavioral Health Providers 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 48 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 49 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 50 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 51 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 52 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. 53 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% 54 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 55 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 56 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 57 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 58 Partnerships With each other Health Homes With PPSs MCOs FQHCs Primary Care Providers IPAs MSOs 59 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 60 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 61 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’ 62