NYAPRS Note: Here’s the behavioral health portion of the recently released summary of the Medicaid Redesign’s efforts.
IMPROVING BEHAVIORAL HEALTH
A Plan to Transform the Empire State’s Medicaid Program
MULTI-YEAR ACTION PLAN
New York’s behavioral health system (which provides specialty care and treatment for mental health and substance use disorders) is large and fragmented. The publicly funded mental health system alone serves over 600,000 people and accounts for about $7 billion in annual expenditures. Approximately 50 percent of this spending goes to inpatient care. The publicly funded substance use disorder treatment system serves over 250,000 individuals and accounts for about $1.7 billion in expenditures annually. Despite the significant spending on behavioral health care, the system offers little comprehensive care coordination even to the highest-need individuals, and there is little accountability for the provision of quality care and for improved outcomes for patients/consumers. This fragmentation problem is compounded since mental health and substance use care and treatment systems are separated, with discrete regulations and funding streams, though there are substantial rates of people with co-occurring serious mental illness and substance use disorders.
Behavioral health also is not well integrated or effectively coordinated with physical health care at the clinical level or at the regulatory and financing levels. The behavioral health system is currently funded primarily through fee-for-service Medicaid, while a substantial portion of physical health care for people with mental illness or substance use disorders is financed and arranged through Medicaid managed care plans. This also contributes to fragmentation and lack of accountability. This lack of coordination extends well beyond physical health care into the education, child welfare, and juvenile justice systems for those under the age of twenty-one.
The fragmented and uncoordinated payment and delivery systems have contributed to poor outcomes, including:
- People with serious mental illness die 15-25 years earlier on average than the rest of the population.
- The leading contributors to this disparity are chronic, co-occurring physical illnesses, which are not prevented and are treated inadequately. (Congruencies in Increased Mortality Rates, Years of Potential Life Lost, and Causes of Death among Public Mental Health Clients in Eight States http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm).
- The majority of preventable admissions paid for by fee-for-service Medicaid to Article 28 inpatient beds are for people with behavioral health conditions, yet the majority of expenditures for these people are for chronic physical health conditions.
- There is an over-reliance on State psychiatric hospitals, adult homes and nursing homes, partly due to the system’s inability to assign responsibility for integrated community care.
- In New York State, under the current Medicaid fee-for-service system, 20% of patients discharged from psychiatric inpatient units are readmitted within 30 days. (http://www.omh.state.ny.us/omhweb/rfp/2011/bho/databook_tables.xlsx)
To address the problems in New York’s behavioral health system, a specific MRT work group was established. This work group, which brought together a wide array of stakeholders, developed comprehensive recommendations, and a reform agenda that is a key part of the overall MRT action plan.
First and foremost, the work group embraced the concept of effective care management for patients with serious mental illness and substance use disorders. The work group went beyond simply advocating for care management, and actually identified a number of key elements of design and practice needed for a managed and coordinated behavioral health care system in New York relevant across the age span. Savings on behavioral and physical healthcare attributable to improved care coordination should be focused on high priority areas including housing, employment services, peer services and family support. The work group reached consensus on key principles and identified critical metrics and indicators that should be measured to determine the extent to which the principles are met. The guiding principles can be found in Appendix B of this document.
One of the key recommendations of the work group is to establish Special Needs Plans and Integrated Delivery System models for providing fully-integrated care management for patients with significant behavioral health needs. These organizations would be risk-bearing and manage the comprehensive needs of the patients they serve. In addition this work group strongly supported the MRT recommendation of a Behavioral Health Organization option which would be a carved-out service that works in tandem with a health plan to achieve service integration. This recommendation is entirely consistent with the overall MRT theme of care management for all and creates a new model of integration that is highly specialized to an important sub-population.
The work group also provided specific recommendation for how to effectively implement Behavioral Health Organizations as an initial step to effective care management, as more comprehensive care management models are allowed to develop. BHOs were a key MRT Phase 1 initiative and are already being implemented. BHOs have proven effective at managing behavioral health services in other states, and will begin by managing high cost FFS behavioral health services through a concurrent review process for FFS inpatient care and a focus on high-quality engagement post discharge.
Eventually BHOs will bear risk, and the work group provided very specific recommendations for how to ensure they are effective.
This work group also discussed the need for integration of behavioral health into primary care settings covered under mainstream plans. Collaborative care and a more robust set of behavioral performance measures were recommended for mainstream plans. A mechanism for funding an appropriate level of services to the uninsured and underinsured needs to be maintained as the system moves into managed Medicaid for all clients with mental health and substance use disorders, and previous funding streams (such as disproportionate share hospital (DSH) payments) are reduced or no longer available.
The work group also created a special team that focused on the behavioral health needs of children.
The team provided recommendations on how the state should step up enforcement of health plans to ensure children with behavioral health needs get the services they need, as well as specific outcome measures the state should track to ensure that children are appropriately served.
Finally, the work group also provided recommendations on how to expand access to peer services, and provided the state with further guidance on how to effectively implement health homes. The work group’s full recommendations, which can be found in the companion document of this report, are perhaps the most comprehensive roadmap New York has ever had for creating an effective behavioral system that is efficiently integrated with other health sectors in order to ensure that the complete needs of complex patients are addressed.