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Getting Ready for Managed Care: What Will It Mean to Consumers, Provider and Peer Professionals? NYAPRS North Country Regional Meeting May 16, 2013 Harvey Rosenthal www.nyaprs.org
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 disabilitiesby promoting their recovery, rehabilitation, rights and community integration and inclusion. email@example.com
Unprecedented Pace of Change Which Services? From Which Providers? In What Networks? With What Goals and Expectations? For How Long? How Reimbursed? With How Much Information and Choice? With What Level of State Oversight?
Backdrop to Healthcare ReformCritical Challenges at Medicaid Systems Level Poor engagement: system not patient failure? Office/program based service delivery Fragmentation and lack of coordination : within medical and BH systems Lack of accountability Reactive vs. preventive Crisis response = ER, Detox and Inpatient
Backdrop to Healthcare ReformCritical Challenges at BH Systems Level Low Outcomes/Expectations: Maintenance, Symptom Management…‘it’s the illness’ Chronic Condition = Lifelong Services Relapses and Readmissions Expected Deficit and illness based not skills or recovery based Power not partnership Poverty not economic self sufficiency
Barriers to Engagement for People with ‘Serious’ BH Conditions • Shame, Stigma and discrimination • Loss of hope • Dehumanizing care • Loss of rights and choices around where you live, with whom and around major life decisions • Isolation; expectations of single, childless life • Idleness: Lack of social meaningful roles work, school.
Barriers to Engagement for People with ‘Serious’ BH Conditions • Poverty (reliance on entitlements) • Loss of personal and family relationships • Loss of sexuality (medication side effects) • Criminalization of emergency care: handcuffs, police, coercion, • Lack of health literacy • Complex eligibility, coverage and admission criteria • Absence of gender or culturally appropriate services
New Groups, New Challenges • ‘At risk, high cost, high needs’ unengaged Medicaid beneficiaries • Lack hope, stable housing, accurate addresses, health literacy, transportation, organization • Often have multiple ongoing conditions including psychiatric conditions, addictions, AIDS, hepatitis, diabetes, cardiovascular illnesses • Medicaid expansion • Commercial insurance
The Cost to People and Taxpayers • People are poor, idle, isolated, segregated and sick…lack health, hope, purpose and community. • People have ‘chronic conditions’, dying 15-25 years earlier due to higher rates of obesity, diabetes, lung and cardiovascular diseases • Federal, state and local governments spend huge amounts of public funds on healthcare, homeless, criminal justice services to people w ‘chronic conditions’ • The total costs of drug abuse and addiction due to use of tobacco, alcohol and illegal drugs are estimated at $559 billion a year. (Surgeon General’s report 2004; ONDCP; 2004; Harwood, 2000)
The Need for Healthcare Reform NYS Example • $54 billion Medicaid Program • 20% (1 million beneficiaries) use 80% of these $ • Hospital, emergency room, medications, services • 40% have behavioral health conditions • NY last in nation in avoidable readmissions, costing $800m to $1 billion • 70% have BH diagnoses, 3/5 of these admissions are for medical reasons • Add 85% unemployment, high rates of homelessness and incarceration Lots of $ Spent, Very Poor Outcomes
ACA HEALTHCARE REFORMSMajor Federal Drivers Triple Aim: improving outcomes, improving quality, reducing cost Medicaid/managed care expansion, BH parity Focus on better coordinated, accountable and integrated physical and behavioral health care Major emphasis on home and community based services and less reliance on institutional care Promoting wellness, preventing relapses upstream Person centered individualized care
The Perfect Storm for Recovery Financial Pressures: federal, state and local governments can’t continue to fund uncoordinated, inefficient, costly services that don’t produce good healthcare outcomes Affordable Care Act: coordinated, active, engaging, accountable, integrated outcome oriented, person centered Managed Care Expansion: brings flexibility and interest in funding peer services and addressing social determinants Mental Health Parity and Addiction Equity Act Olmstead Enforcements: pressures states to serve people with disabilities in most integrated not institutional settings Consumer, Rehab & Recovery Movements: have ready made models to promote choice, rights, wellness, community integration, life beyond services, alternatives
Recovery Movement Recovery is not only possible, it is expected Providing tools to promote and protect choice: Wellness Recovery Action Plans, Advance Directives, Recovery Capital Scales and Recovery Management Plans Outreach: going to the person, not expecting the person to come to us Engagement based on hope, empathy and starting where the person is
Recovery Movement We are not responsible for the ‘illness’ or trauma but we are responsible for our recovery and our choices We are not our illness or label Recovery = risk and responsibility Can’t be ‘person-centered’ and ‘self directed’ if we don’t explore what we want and make a commitment to try Fully informed choice
State Medicaid Redesign Plans Integrating services to work in a more coordinated, collaborative, activist and accountable fashion through federally incentivized health home networks Integrating health, pharmacy, mental health and addiction services under managed care Rewarding outcomes vs paying for visits
From Fee for Service to Managed Care Some states are preparing to ‘carve in’ Medicaid behavioral health services, turning them over to the coordination of managed health insurance plans . Plans will be paid on a ‘capitated’ per person per month basis for outcomes not visits. Plans will authorize payments to contracted providers and networks based on their success in engaging and serving beneficiaries….and reducing avoidable costs.
Our Opportunity in Managed Care Managed care companies and BHOs have great flexibility beyond traditional Medicaid rules and more narrow medical necessity restrictions to buy approved non traditional services that are proven to work, if the state’s design expects, rewards and enforces those values.
Moving Behavioral Health Services Into Managed Care By October 2014, currently ‘carved out’ Fee for Service OMH and OASAS services will be integrated into upstate managed care plans, either on their own or in partnership with a “qualified” Behavioral Health Organization.
Moving Behavioral Health Services Into Managed Care • Those services include OMH/OASAS mental health and substance abuse inpatient and clinic services • OMH Medicaid services like PROS, ACT, IPRT, ACT, CDT, Partial Hospital, CPEP, Targeted Case Management and rehab supports within community residences and • OASAS Medicaid services like Opioid treatment and outpatient chemical dependence rehabilitation.
Health and Recovery Plans (HARPS) • Will provide a range of more intensive services for individuals with ‘significant behavioral health needs’.
Health and Recovery Plans (HARPS)Enhanced Mental Health Services • Services in Support of Participant Direction: Information and Assistance in Support of Participant Direction and Financial Management Services • Crisis: Crisis Respite • Support Services: Community Transition, Family Support, Advocacy/ Support and Training and Counseling for Unpaid Caregivers
Health and Recovery Plans (HARPS)Enhanced Mental Health Services • Empowerment Services: PEER SUPPORTS • Service Coordination • Rehabilitation: Pre-vocational, Transitional Employment, Assisted Competitive, Employment, Supported Employment, Supported Education, Onsite Rehabilitation, Respite and Habilitation
Sample HARP Outcome Measures • Increased access • Service engagement • Physical health improvements • Participation in employment; • Enrollment in vocational rehab services and education/training; • Housing status; • Community tenure; • Criminal justice involvement; • Peer service use and • Improving functional status
Managed Care Designs • Mainstream plans can be approved to operate HARPs by themselves if they meet ‘rigorous’ state standards. • Such plans may also choose to partner with a BHO to meet those standards.
BHOs USING PEER SERVICES Magellan: self directed care program in Pennsylvania; crisis alternatives in Arizona; psychiatric rehabilitation in Iowa Optum: peer bridgers in Wisconsin, Tennessee, New York, New Mexico; peer warm line, crisis respite and bridgers in Washington Community Care: recovery institute, learning collaborative, supported housing reinvestment; consumer/family satisfaction teams ValueOptions: self directed care program in Texas, peer services and consumer research and evaluation in Massachusetts
Timelines • Spring 2013: Program design finalized • Winter 2013: Contract Requirements for MCOs, HARPs finalized: RFQ posted on website for upstate groups • Summer 2014: Qualified MCOs and HARPs are selected for upstate • Fall 2014: HARPS, MCOs are operational upstate
Managed Behavioral/Physical Careand Health Homes DOH/OMH/OASAS MCO/BHO (A) MCO/BHO (B) HARP HH Team HH Team HH Team HH Team HH Team = Physical and/or behavioral health care provider 28
What are Health Homes? A health home is a ‘hub’ not a house Health homes are multidisciplinary teams comprised of medical, mental health, and addiction treatment providers and social services organizations who work together to improve care and reduce costs for those with more serious ongoing conditions
Health Home Network Leader • Health home lead agencies provide: • Dedicated care managers who assure that enrollees receive all needed medical, behavioral, and social services from their assembled networks of treatment, housing and social services • in accordance with a single care management plan • that is shared with all providers via an electronic healthcare record
Heath Homes Goal • Health homes are accountable for reducing avoidable health care costs, specifically preventable hospital admissions/readmissions, skilled nursing facility admissions and emergency room visits and meeting quality measures. • Active engagement • 24-7 response • Focus on well coordinated discharge and treatment planning
Health Home Funding Health home leaders get a monthly rate for each person served that pays for care management, electronic health care record system and administrative costs. Health home network members continue to bill existing funding streams….until the move to managed care.
Following the Money… Current plans are to ‘lock in’ and track all carved in behavioral health dollars to guard against migration of funds and to reinvest all savings into enhancing needed services At the outset, the average per person per year cost for HAPR services is $30,000. The recently enhanced monthly rate for ‘high touch’ health home enrollees with behavioral health needs is about $950.
Hudson River Healthcare Hospitals: Good Samaritan Hospital; Hudson Valley Hospital Center; St. Francis Hospital and Health Centers; St. John's Riverside Hospital; Vassar Brothers Medical Center Health Plans: Hudson Health Plan Medical Providers: Health Quest Medical Practice; Healthcare Opportunities Provided with Excellence (HOPE) Center; Institute for Family Health Misc: Arms Acres; AIDS Related Community Services (ARCS); Hudson River Housing; St. Christopher's Inn; Sullivan County Department of Community Services; Taconic Health Information Network and Community (THINC RHIO); Together Our Unity Can Heal, housing, social , disability services
Hudson River Healthcare BH Providers: Dutchess County Department of Mental Hygiene; Hudson Valley Mental Health; Human Development Services of Westchester; Lexington Center for Recovery; Mental Health America of Dutchess County; Mental Health Association of Westchester; Mental Health Association of Rockland; Occupations; Putnam Family and Children's Services; Rehabilitation Support Services; Rockland County Department of Mental Health; The Recovery Center; Gateway Community Industries; Westchester Jewish Community Services (WJCS); Westchester County Department of Community Mental Health;
Health Home Advantages for Consumers Integrated Care Help with Navigating the Health Care System Better Access Better Coordination Wellness and Person Centered Focus on Skills to Stay Healthy Availability of Peer Based Recovery Supports
Health Home Advantages for Providers • Part of an Integrated Care Team • Access to Referrals • Electronic Data Sharing • Outcome Focused and Accountable • Positioning for Managed Care • Health Homes are organizing networks which will contract with managed care payers
Critical Value of BH Services Behavioral health providers bring vital services to networks, e.g., care management, rehabilitation and recovery services, skills in engagement and motivation, housing, employment, peer outreach, engagement, diversion and support services, clinical treatment for ‘co-occurring’ conditions
Housing First 2000 “Pathways to Housing: Supported Housing for Street-Dwelling Homeless Individuals With Psychiatric Disabilities” Psychiatric Services Tsemberis and Eisenberg An innovative ‘harm reduction’ housing and support program model was able to achieve an 88% service retention rate and general stability among a group of primarily young men of color with psychotic disorders and previous histories of homelessness and non-participation with services http://ps.psychiatryonline.org/cgi/content/abstract/51/4/487
Housing, Employment and Medicaid Savings • A 2002 University of Pennsylvania study found supported housing produced an average of $16,282in savings from reduced use of hospitals, ERs, shelters et al. • A May 2006 Mathematica study found that “on average, Buy-In participants cost Medicaid $984 per-member per-month (PMPM) in 2000, almost 40 percent lower than the cost of other Medicaid enrollees with disabilities.” • Criminal Justice Diversion, Re-Entry services too
Westchester County Care Coordination Project 2007-10 • Intensive program consisting of care manager, peer mentor and self directed budget • Total local funds: $176,000 for 48 people • Reductions • Medicaid services: 35% • Incarceration: 53% • State hospital: 78% • Total: 53% $2.3 million down to $1.2 million
Peer Services in Health Homes • Health homes can re-program care management dollars to buy peer services that can promote: • Outreach and engagement • Recovery coaching and supports before, during and after treatment • Hospital/Prison/Adult Home to community transitional support/bridging • Wellness self management support • Crisis diversion and relapse prevention
Peer Services in Health Homes • Sample arrangement…working in subcontract with a health home to be part of a ‘service triangle’: • Care manager • Nurse • Peer wellness coach/navigator: outreach, engagement, service planning, recoverycoaching, diversion, advocacy
NYAPRS/OPTUM Wellness coaching: One Person’s Outcomes • Abstinent for 1 year • Relapsed 1 year post rehab-went back to rehab-returned to abstinent lifestyle • 2009-prior to enrollment: 7 detox stays (4 different facilities) $52,282 • 2010-1 detox, 1 rehab (referred by the CIDP team) $20,650. • 2011-1 relapse with detox/rehab no claim yet.
New Roles, Groups for Peer Services From a rights protection, advocacy and empowerment focus for people within the mental health and substance use treatment system to… Bringing hope, wellness, resilience and rights protections to a broader array of people (pre-SSI and private insurance beneficiaries) as a part of the greater healthcare system
Peer Service Innovations Can Play Crucial Roles in Improving Care, Health, Cost • Helping to address the challenges of: • Effective person-centered outreach and engagement; bringing services to the beneficiary • Successful transitions from hospital and other institutions to the community • Reduced ER visits and readmissions to inpatient and detox
Peer Service Innovations Play Crucial Roles in Improving Care, Health, Cost • Effective crisis management and diversion supports and services • Critical health literacy training and coaching that promotes improved self management and improved health outcomes • Advancing active participation in outpatient services
Beyond Peer SpecialistsExamples of Peer Run Specialty Services Peer Crisis Diversion: warm lines, respite house Peer Bridging Recovery Coaching Peer Wellness Coaching/Navigator Rights Protection & Advocacy: Ombuds Life Coaching: work, economic self sufficiency Peer Supported Housing Services not Programs
DATA IS KEYPeer Service Outcomes • 2010 study: 90% of PEOPLeInc’s Rose House crisis respite guests did not return to hospital in the following two years • NYAPRS Peer Bridger programs helped support a: • 71% drop in NY state psychiatric center readmissions • 50% drop in numbers of people hospitalized in local Medicaid psychiatric inpatient units and in total hospital days when admitted • 2010 Optum Health Peer Link reduced hospital days by 90% in Wisconsin, by 72% in Tennessee
DATA IS KEYPeer Service Outcomes 2010: Mental Health Peer Connection’s Life Coaches helped 53% of individuals with employment goals to successfully return to work 2011: Housing Options Made Easy helped 70% of residents to successfully stay out of hospital in the following year