NYAPRS Note: Here’s a copy of NYAPRS’ recently submitted comments to support and help shape New York’s proposal to extend our Delivery System Reform Incentive Payment (DSRIP) program by:
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requiring a 30% set aside for community based behavioral health agencies,
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raising requirements to contract with community based agencies and address the social determinants of health,
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extending attribution to behavioral healthcare providers,
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supporting recovery focused organizational change and an appropriate roles for the peer workforce,
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increasing the use of peers and peer engagement and education to increase enrollment in Home and Community Based Services,
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using DRSIP dollars to advance workforce recruitment and retention,
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encouraging the use of culturally competent patient incentives,
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ensuring choice in the sharing of personal healthcare information and
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essential roles for consumers and advocates in DSRIP provider and network operations and state oversight of the program.
Our comments are in reaction to the state’s draft waiver amendment proposal which can be found at:
https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/2019/docs/amendment_req.pdf.
Learn more about our current DSRIP program at
https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/.
Finally, look for more information in future E News postings about the state’s final submission and the federal government’s consideration and actions.
NYAPRS Comments on New York’s DSRIP 2.0 Amendment Request
November 4, 2019
On behalf of the New York Association of Psychiatric Rehabilitation Services (NYAPRS), I would like to express our great appreciation for this opportunity to offer comments on New York’s draft Delivery System Reform Incentive Payment Program (DSRIP) amendment.
Background
Since 1981, NYAPRS has forged and supported a unique coalition comprised of thousands of New Yorkers with major behavioral health conditions and staff from upwards of 100 recovery-focused community agencies to jointly advocate for and support the recovery, rehabilitation, rights and full community integration of our community members, going back to times when none of these were considered possible by our field and our society.
We have implemented this great mission through a combination of grassroots advocacy, provider and consumer training and technical assistance and through the creation of nationally acclaimed peer support service models. At the same time, NYAPRS’ work is personal for us since so many of NYAPRS’ and our member agencies’ staff are people in mental health recovery, like me.
In that spirit, we have sought to represent the consumer perspective on state Medicaid reforms through my service on the Medicaid Redesign Team, the Behavioral Health and Value Based Payment Work Groups and the Behavioral Health Clinical Advisory Group. NYAPRS has also worked arduously to promote and provide both consumer and provider education in support of a number of MRT programs, most notably the HARP, Health Home and Home and Community Based Services (HCBS) initiatives, as we view bringing Medicaid reimbursement for recovery focused services to be a landmark achievement for New York State.
We write today in very strong support of New York’s application for a DSRIP Amendment that would allow additional time and funding support to permit successful initiatives to fully mature while the state transitions to a value-based payment system that is based on high quality individual and system outcomes.
Yet, so much more is needed to meet our ambitious goals. Following are a number of recommendations that we believe will strengthen DSRIP 2.0’s enormous potential to meet state and national goals of promoting healthy lives while reducing avoidable costs.
Recommendations
A 30% Set Aside for Community Based Organizations
Recognizing the high percentage of DSRIP eligible members who live with major mental health challenges, we had expected that community recovery providers with decades of expertise in effectively engaging and supporting members of our community would be at the forefront of driving the new systems of care developed via DSRIP 1.0.
Yet, for most of that period, the vast majority of DSRIP funds were used to stabilize or support primarily institutional organizations, many of which have chosen to ‘build rather than buy’ those community behavioral health services. For example, by November 2018, mental health prevention, treatment and recovery service providers had received just 1.8% of all DSRIP funding received by Performing Provider Systems around the state while community agencies struggled to sustain themselves and their workforce due to inadequate funding and run away staff vacancy and turnover rates.
NYS government must be just as concerned about strengthening community behavioral health and related agencies to play a pivotal role in achieving DSRIP’s transformational goals, as it has been about stabilizing our local hospitals and nursing homes. Just as the DSRIP 2.0 proposal includes $500 million to aid distressed hospitals, we look forward to seeing that hard-pressed community behavioral healthcare agencies are afforded a meaningful portion of the $5 billion DSRIP performance and $1.5 billion social determinants of health (SDH) related funding so that they are best positioned to properly support our most vulnerable New Yorkers.
It’s not enough to simply keep people out of emergency rooms and hospitals…it’s imperative that we offer the right kinds of support and opportunities to allow our most vulnerable New Yorkers to manage their health and succeed in their home communities, with the support of behavioral health providers with the greatest experience and success.
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New York should live up to our well-deserved reputation as a national leader in innovative Medicaid reform by meeting, if not surpassing, the approach adopted by our neighbors in Massachusetts, who are devoting 30% or their DSRIP funds to community based providers ($547 million of a $1.8 billion. For more details, see https://www.mass.gov/info-details/massachusetts-delivery-system-reform-incentive-payment-program#community-partners-(cps)-and-community-service-agencies-(csas)-
Raising Requirements to Contract with Community Providers
While our amendment rightly points out that New York was first in the nation to require that value-based initiatives must include contracting with a minimum of one community-based organization (CBO), one CBO arrangement is simply no longer acceptable.
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We must take the next step forward in DSRIP 2.0 by substantially raising the number of required CBO contracts in each health plan risk-based arrangement.
Raising Requirements to Address the Social Determinants of Health in Value Based Payment Contracting
There is ever increasing and powerful evidence that addressing the social determinants of health is critical to helping people to improve their health while reducing avoidable healthcare, social and criminal justice system costs. New York currently requires managed care plans to contract for at least one SDH intervention in risk-sharing VBP contracts but, once again, that is no longer acceptable.
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DSRIP 2.0 provides us with the opportunity and $1.5 billion in funding to substantially raise the number of required SDH arrangements in the VBP environment. We believe that each contract must take into account measures that include each of the following: improved income and employment status, greater access to housing and reduced involvement with the criminal justice system.
Further, we are greatly encouraged by the state’s intention to invest Medicaid dollars in housing and look forward to getting more details.
Social Determinant and Recovery Related Outcome Measures
In a pay for performance value-based payment environment, plans and providers focus on meeting specified outcome measures that are identified by the state. Currently, New York’s accepted behavioral health measures solely include medically based HEDIS outcomes like follow up with mental health clinicians within 7 days of discharge from a psychiatric hospitalization, adherence with antipsychotic medication and potentially preventable mental health related readmission rates.
At the same time, state Quality Measurement experts have considered but not endorsed the addition of critically important social determinant and recovery related measures that include maintaining/improving employment or higher education status, the maintenance of stable or improved housing status and no or reduced criminal justice involvement.
While some people may need or want medication and clinical care, all people need housing, food and the financial employment or entitlement based resources to meet their most basic needs and that allow them to avoid crises that all too often lead to costly and preventable relapses and hospital admissions or readmissions.
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State officials must greatly accelerate the process to validate, use and financially incentive recovery and social determinant related personal outcomes and move us beyond sole reliance on medically based process measures.
In that vein, we should give equal importance to consideration of the use of Patient Reported Outcomes, per a recommendation of the VBP Advocacy and Engagement Group (https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/docs/2015-12-04_advocacy_engagement-meeting4.pdf, slides 11-14).
Attribution
New York currently employs a VBP attribution model that assigns responsibility for the coordination and outcomes of care for Medicaid members, as well as the distribution of savings, to primary care providers and networks.
But many members are both unaware of this assignment and/or are not actively engaged with a medical provider.
In fact, many Medicaid members are solely engaged with behavioral health care providers who have more familiarity and experience in addressing their unique needs and who have a proven record of success at forming meaningful relationships and alliances that foster improved health and community inclusion and reduced use of hospital and emergency services.
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The state should extend attribution to behavioral health providers when they represent the primary health care relationship in a member’s life and implement this practice in DSRIP 2.0, which will represent a huge win for the members, their providers and the state.
Ensure Widespread Access to Fidelity Level Peer Support
We now have significant and powerful evidence of the great effectiveness of peer supporters (people who use their lived experience of recovery from a broad variety of behavioral and physical healthcare conditions) in engaging, earning trust, fostering hope and supporting people with the most challenging conditions and circumstances to improve their health and advance their lives.
Peer delivered services are unique in the way they are conceived and delivered. In that spirit, they must not be regarded as a replacement for case management or transportation services or as staffers who primarily connect people with clinical and medical care. Ultimately, they are about relationships that matter, especially during the hardest times. They are especially effective because they begin where the person is, both in terms of what they identify as their primary needs and goals and as to where and how they live.
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Accordingly, new Value-Driving Entities must be afforded the flexibility to use earned dollars to hire, deploy and support peer professionals and in an appropriate role and environment (see below).
Organizational Change that Support Recovery and Peer Support Approaches
At the same time, organizational culture determines whether peer and other recovery services are successful. For example, NYAPRS’ longtime experience as recovery training and technical assistance facilitators in New York and nationally ave made it clear that simply adding peers to an organization’s workforce will not succeed unless those organizations have undergone a change management process to move from a more traditional illness, symptom management and maintenance-based set of beliefs and practices to ones that focus on wellness, recovery, personal choice, strengths, dignity and the ability to engage with someone who has a similar experience and background.
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The state, provider networks and providers must make a serious commitment to fund efforts to promote fundamental recovery-based culture change across PPS administrators, provider leads, middle management and direct care workers. Training and technical assistance of this kind will more than pay for itself going forward as the recovery focused designs and trained and energized peer and non-peer staff lead to improved engagement, outcomes and savings.
Advance Provider and Consumer Understanding of MRT Related Initiatives
Our experience as peer to peer community educators continues to show us that large numbers of beneficiaries and community providers still don’t sufficiently understand the basic elements, alignment, goals and outcomes of the HARP, Health Home and HCBS initiatives.
We strongly urge the state to use a portion of DSRIP 2.0 Workforce funds to educate and encourage staff and consumers to knowledgeably promote enrollment in all 3 programs. Such funds can also be used to help successful initiatives that were created from the OMH funded Adult BH HCBS Quality/Infrastructure Programs to continue to go forward once those funds have been exhausted and while sustainable funding from health plans can be developed.
Increasing Engagement and Enrollment in Health Homes and Home and Community Based Services
Finally, we have long advocated for the use of ‘peer health home bridgers’ to sensitively and effectively engage individuals and to personally ‘walk them’ through the complex process of enrollments into Health and Recovery Plans, Health Homes and Home and Community Based Services.
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We must find a way to use waiver dollars to pay for highly engaging and effective peer services before involvement in the HCBS. This can especially allow peer professional who are especially skilled and successful at outreach and engagement to support someone through the daunting process of enrollment into the HARPs, connection with the health home care manager, completion of the assessment Hand plan of care and a firm engagement with HCBS initiatives.
Staff Recruitment and Retention
A recently compiled survey pointedly demonstrated the magnitude of New York’s human services workforce crisis, showing 35% statewide turnover rates and 14% vacancy rates for the behavioral health workforce alone. In New York City, the turnover rate was over 45%. Underfunding human services is also an equity and racial disparity issue: the nonprofit human services workforce is 81% female and 46% women of color. The average pay for our dedicated workforce is so low that 60% of those working in our human services sector were utilizing or had a family member utilizing some form of public assistance benefit such as Medicaid or food stamps.
In many instances, DSRIP promising practices have relied on non-traditional, non-clinical workforce to achieve project goals. Over the DSRIP 2.0 period, there must be ongoing flexibility for Value-Driving Entities to invest earned dollars to support this workforce as MCOs and CBOs design VBP approaches to sustain these models in the long term.
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A portion of the $1 billion DSRIP 2.0 Workforce development funds should be used to allow community agencies to attract and/or retain a talented workforce and sustain critically important consumer-staff relationships as agency efforts mature to secure sustainable funding from MCOs and other payers. These funds could be used to provide funding and tuition reimbursements based on need.
A Consumer-Centered System of Care
Patient Choice and Privacy Protections
While NYAPRS has long supported the use of electronic healthcare systems, Regional Health Information Organizations and the Statewide Health Information Network of New York (SHIN-NY), we strongly value the role of informed consent in the sharing of patient information.
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That’s why we have urged the state, in both the Privacy and Confidentiality and overall Value Based Payment work groups, to continue with a Opt-In enrollment program into the RHIO that is tied to a strong patient education function. There are many examples, both within New York and nationally, that enrollment rates into RHIOs tend towards the mid 90% range when a strong Education and Opt-In program is deployed. NYAPRS and many disability rights groups do not support approaches that permit full information sharing UNLESS patients see, understand and approve that option.
Culturally Competent Patient Incentives
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In keeping with the recommendations of the VBP Advocacy and Engagement subcommittee, we also urge the state to accelerate its work with health plans to offer financial and other incentives for patients who take appropriate steps to improve their own health.
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We want to ensure the use of culturally and linguistically competent incentives as identified by a recommended ‘Expert Group for Achieving Cultural Competence in Incentive Programs’, page 9:
Consumer Input and Oversight
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The state should ensure that consumers and other advocates play prominent roles on the boards and advisory bodies of the new Value-Driving Entities. We must also ensure a strong continued role for the vitally important Project Approval and Oversight Panel (PAOP).
Thank you again for this opportunity to offer comments on New York’s proposed DSRIP amendment and value-based payment initiative.
Harvey Rosenthal, CEO
New York Association of Psychiatric Rehabilitation Services