New York State BH Community Upset Over Loss of Billions for Medicaid Reform
Mental Health Weekly March 2, 2020
Mental health advocates and providers across New York State have expressed disappointment and concerns over the Trump administration’s denial last week to extend its DSRIP Medicaid waiver program to further improve care and reduce avoidable hospitalizations. State officials were seeking $8 billion more in federal funding for the program’s extension over the next five years.
The Delivery System Reform Incentive Payment (DSRIP) program, which commenced in 2014, is the main mechanism by which New York state has been implementing the Medicaid Redesign Team (MRT)’s waiver amendment. DSRIP’s purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25% from 2015 to 2020, according to the New York State Department of Health (NYSDOH).
NYSDOH in November submitted a formal request to continue its “groundbreaking” Medicaid waiver program. The Centers for Medicare & Medicaid Services (CMS), in response, denied the request. The current waiver is in place until it expires on March 31, 2020 and had allowed New York state to reinvest $8 billion of savings achieved through Gov. Andrew Cuomo’s MRT in critical initiatives that improve how the state delivers Medicaid services, according to NYSDOH.
As of June 30, 2018, the waiver reduced avoidable hospitalizations by 21% and preventable hospital readmissions by 17%, which has resulted in better performance of other significant areas of care, such as behavioral health, NYSDOH officials said.
Representing Best Practices
The DSRIP application submitted by the state in late November focused heavily on replicating best practices from DSRIP 1.0 and on continuing to spread value based contracting, Lauri Cole, executive director of the New York State Council for Community Behavioral Healthcare, told MHW. “I do not believe the state’s interest in spreading value based care/contracting will disappear despite denial by CMS of DSRIP 2.0,” she said.
BH community providers (as compared to hospitals and other institutional providers) received very little in the way of direct funds from DSRIP 1.0, said Cole. “Last month, the Senate Health Chair introduced a bill solicited by our organization along with our partners at the Community Health Care Association of New York State to address this inequity going forward,” Cole noted. The Assembly Health Chair was preparing to introduce a ‘same as’ bill. The bill requested that at least 40% of any new funds received by New York state under a new DSRIP program would be directed to those community based organizations that received so very little in the DSRIP 1.0 program, and who were not specifically identified to receive funds in the DSRIP 2.0 proposal, she said.
It’s important to preserve some of the key gains that have been made across the state, Cole added. “It is safe to assume New York State wants to continue to build these large integrated networks (ACOs, etc.) so as to continue to create leadership entities whose roles include responsibility for ensuring quality integrated care that meets the unique needs of local/regional communities, she said. “New York State has a lot at stake in innovating and integrating as much as it can,” said Cole. “It’s counterproductive to return to the status quo.” Cole noted it’s still early in the process. She thinks the governor will try to revisit this issue with the Trump administration. “It seems like New York hasn’t fully given up yet,” she said.
NYAPRS
“CMS’s action represents a very big disappointment, at a time when we were starting to build on some very promising advances,” Harvey Rosenthal, CEO of the New York Association of Psychiatric Rehabilitation Services (NYAPRS), told MHW. “It’s a huge loss of a fundamental opportunity to build on some very innovative networks and approaches that were showing promising successes in improving health and reducing costly and avoidable emergency and inpatient use across New York state,” said Rosenthal.
Of particular importance, DSRIP 2.0 was poised to invest $1.5 billion to promote approaches to address critically important social determinants of health like stable housing and finances, social connection and reduced involvement in the criminal justice system, said Rosenthal.
Rosenthal noted that $625 million in unspent monies by the 25 regional DSRIP entities will be cancelled. In addition, CMS has also at the same time rejected the state’s new application for an additional $8 billion, he said. He added, “so anything that was expected is no longer available and that as of April 1st there will no longer be DSRIP funding.”
”Some of the most at risk individuals who could have been better served by DSRIP 2 include people who are hungry, isolated, homeless, or have recurrent episodes of mental illness or substance use disorders. More crisis services, rehabilitation, support and improved wellness in the community could have been enhanced…..said Rosenthal.
Services could have been provided to help with people with social services needs, emergency housing, and mental health and addiction treatment, said Rosenthal. “That’s why you need multiple providers in hospitals, outpatient clinics and also peers and social services,” Rosenthal said. “DSRIP at its best brings all groups to address the range of needs that the population presents.
”Saving Billions
The state approached the CMS for an extension of the DSRIP program because New York had saved the federal government billions of dollars, said Glenn Liebman, CEO at the Mental Health Association in New York State (MHANYS). “In return, we wanted to get the waiver to move forward,” Liebman told MHW.
During the first iteration of DSRIP, the state saved billions of dollars by creating the Medicaid Redesign Team, said Liebman. MHANYS remained very hopeful, especially from a mental health perspective, that DSRIP would reach that 25% decline in avoidable rehospitalization over five years, he said.
“Most of the mental health work is done in the community,” Liebman said. “We were hoping the first DSRIP would flow to community providers. Unfortunately, it didn’t.” The programs by DSRIP were driven by hospitals, which ended up taking the bulk of the funding, he said. “Community based programs do this work every day,” Liebman stated. “We keep people out of hospitals and into communities. We should get more funding from DSRIP to be able to do that.” Liebman added that “we were very disappointed the CMS did not give the funding to New York and put more emphasis on community based programs.
Ongoing Campaign
Liebman holds high hopes for its ongoing campaign, “3for5 to Ensure Communities Thrive,” to push for a 3% funding increase every year for the next five years.
The state’s nonprofit human services community-based providers for mental health, substance use, developmental disabilities, foster care, child welfare, domestic violence and other groups launched the campaign late last year (see MHW, Dec. 23, 2019). “We’re all speaking with one voice,” said Liebman, who intends to push the state legislature for the funding increase (separate from the DSRIP track).
“Hopefully we’ll get the funding in the budget to enhance the work of community based providers.” The state budget has to be completed by April 1, Liebman said. “We have five weeks before we’re marshalling our resources and grassroots advocacy with legislators and the governor to make this happen,” he said.
Had DSRIP 2.0 happened, funding would have definitely gone to community based providers, he said. “It would have enhanced the work of our human services programs,” Liebman said.