New York State’s behavioral health care transformation is the most significant shift in mental health policy since deinstitutionalization over a half a century ago. Despite improvements that emerged as a result of the shift from an institutional to community-based system of care, significant inadequacies continue to hamper the mental health system. The current behavioral health care reform efforts present a vital and timely opportunity to vastly improve the care delivery system for thousands of New Yorkers with unaddressed mental health needs.
However, there are numerous nearly simultaneous complex policy shifts that will impact different populations of individuals with varying levels of mental health needs across the health care sector. All require adequate attention and planning to ensure not only effective inclusion of mental health but sound, comprehensive reform. Some highlights of the broad system changes are:
Medicaid Redesign: NYS’s Medicaid Redesign Team, which was formed to conduct a fundamental restructuring of the public health program, has approved an enormous system wide transformation. The changes include a vision of integrated care management for all Medicaid beneficiaries that will manage the complete needs of individuals’ acute, long-term and behavioral care. This includes a major area of focus for the behavioral health community – the shifting of Medicaid-only beneficiaries with serious and persistent mental illness from fee-for-service to managed Medicaid in 2015.
Individuals will be enrolled in one of two behavioral health managed care models, mainstream Managed Care Organizations (MCOs) or Health and Recovery Plans (HARPs). To advance the vision of care management for all, New York State is taking advantage of incredible opportunities through the Affordable Care Act (ACA). Health homes, a financing and care delivery model option under the ACA, are already coordinating and managing care for NYS Medicaid eligible individuals with chronic physical and/or behavioral health conditions also referred to as “high cost, high need” individuals. Health homes will be a fundamental component of the managed Medicaid program.
Beginning in July 2014, dual eligibles (individuals enrolled in both Medicare and Medicaid) in the downstate region of NYS will be transitioned to the Fully Integrated Duals Advantage (FIDA) Program, an ACA demonstration opportunity, which will provide a comprehensive package of services and coordinate all care, including behavioral health services.
Affordable Care Act Implementation: Beyond the establishment of health homes and the FIDA demonstration, NYS is implementing numerous other policy changes afforded to the state through the ACA. Among them is NYS’s own health plan marketplace, a major feature of the ACA, which was launched in October 2013. NY’s marketplace will help thousands of New Yorkers with mental health conditions but without health coverage shop for and enroll in health insurance, an essential benefit of which is coverage of mental health and substance use disorders.
Mental Health Parity: Our nation has long awaited mental health parity. In November 2013, the final Federal Parity Rules were issued to implement The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008, which required health plans that offer mental health and substance use disorder benefits to cover them to the same extent that they cover medical and surgical benefits. Additionally, the ACA significantly extends the reach of MHPAEA, requiring that all small group and individual market plans comply with federal parity requirements and that plans offered through the marketplace include coverage of behavioral health and at parity. This final rule, along with the ACA’s extension and the health plan marketplace, will give many more New Yorkers access to needed mental health services.
Community Transition: In addition to the above noted reform efforts, a few different policy shifts will transition individuals with psychiatric disabilities from institutional settings to community-based care. Over a three-year timeframe, NYS is planning to consolidate its inpatient psychiatric facilities, closing six of its 24 state hospitals, and converting designated areas into Regional Centers of Excellence (RCEs). RCEs will be state operated regionally-based networks of inpatient and community-based services. Additionally, as a result of separate lawsuits, NYS must transition a select group of people with serious mental illness who are residents of adult and nursing homes into the community. Over a five-year period, NYS will move more than 4,000 adult home residents with serious mental illness in NYC into community housing. Over a similar time period, the state must also transfer hundreds of out-of-state nursing home residents, some with serious mental illness who were transinstitutionalized, back into NYS. These significant policy transitions require careful planning to ensure that appropriate community-based resources are developed.
All of these sweeping changes have the great potential for achieving the aims of health reform, also known as the Triple Aim: Better coordinating care delivery, improving recovery, health and mental health outcomes, and decreasing the costs of care. But these policy shifts must be used to leverage a comprehensive, sustainable, coordinated behavioral health infrastructure that implements specific changes needed to substantially improve policy and practice for those with historic and future diverse, unmet mental health needs. The needs for this infrastructure are highlighted below:
- Maintain and expand mental health as a major component of health policy reform including maintenance of parity, enhanced integration of behavioral and physical health care, and workforce development
- Build population-based mental health policy for those whom mental health service expansion would be beneficial. Progressive expansion of the mental health system should focus particularly on underserved populations including (1) children and adolescents, (2) older adults, (3) minorities, (4) people with serious mental illnesses who do not use traditional services, (5) people with serious mental illnesses who are being de-institutionalized, (6) people who are homeless, (7) people with co-occurring severe mental, substance use, and physical health conditions, and (8) military personnel, veterans, and their families.
- Expand services for adults with serious mental illness who are transitioning into the community and for those who are not adequately served by the current mental health system including those who are homeless, involved with the criminal justice system, living in adult homes or nursing homes, and those who are unwilling to use mental health services
- This effort should include expanding initiatives which emphasize recovery, enhance access to mainstream society, and improve quality of life. It should also include a mechanism for adults with serious mental illness who are enrolled in Medicaid behavioral health managed care plans, specifically Health and Recovery Plans (HARPs), to dis-enroll based on recovery benchmarks.
- Prepare for predictable, major demographic shifts, especially for older adults and cultural minorities and immigrants
- Access Issues
- Ensure and monitor implementation of parity between health and mental health insurance coverage
- Expand the use of technology to engage people who are otherwise not willing, or able, to access care
- Assure that care is available to people who continue to lack insurance coverage or with inadequate insurance coverage, including immigrants and undocumented aliens
- Quality Issues
- Enhance integration of behavioral and physical health care
- Assure widespread knowledge of state-of-the-art treatment and rehabilitation
- Develop adequate monitoring and evaluation tools and mechanisms that are population based
- Retool the behavioral health workforce and build it appropriately for the future demand for care, including:
- Addressing the shortage of mental health professionals, especially for children, older adults, and minorities.
- Addressing the need for enhanced clinical and cultural competence
- Expanding the use of peers, family members, and paraprofessionals
- Provide family support to assist families who are providing housing and other forms of care for people with mental illness
- Commit to combat discrimination against people with mental illness and educate the public about mental illness to foster better societal acceptance and integration
- Overcome state and local financial and regulatory barriers that prevent further progressive development of a comprehensive community-based system of care
Some of these recommendations are being embedded in the redesign of the behavioral health care system, while others have not been considered. As we continue to craft bold, far-reaching policy changes, we must use this extraordinary time to develop even bolder, more creative changes to achieve the promise of visionaries before us who imagined a society where all people with mental health needs are fully integrated in their communities with access to high quality, recovery-oriented mental health supports. This time is like no other, so we must use it wisely.