The New York State behavioral health system’s evolution toward greater care integration and accountability and a focus on recovery will include larger roles for managed care organizations in developing and managing systems of care, expanded care coordination and case management services, and new practice models. The principles and goals of this transformation, articulated in the Medicaid Redesign Team’s Behavioral Health Workgroup report and recommendations (www.health.ny.gov/health_care/medicaid/redesign/docs/mrt_behavioral_health_reform_recommend.pdf), should continue to inform this process. A transformed system will work in an integrated and interconnected manner toward a holistic set of goals for each person, including physical health, behavioral health, and social well-being. Our challenges are in making the policy and design choices most likely to achieve these results.
Here are some of the areas that we at the New York City Department of Health and Mental Hygiene will be focused on as this transformative process continues:
Setting the right metrics of success. Clear, quantitative measures, to which plans and providers are held accountable, are perhaps the most essential elements of a transformed system and are the best ways to drive system change. Consequently, the metrics selected are critically important. They should address the following specific areas: increasing ongoing engagement in outpatient care; improving transitions from inpatient to outpatient care; reducing avoidable use of inpatient and emergency services; maintaining housing and employment and reducing incarceration; delivering best practices for particular behavioral health conditions and preventive clinical services for physical health issues; and maximizing consumer satisfaction with services. Obviously, accountability for social outcomes – for recovery – will be particularly challenging for plans and for the system as a whole, requiring new approaches and collaboration and coordination with government systems and services. In addition, a key aspect of using metrics to measure performance is to not examine only averages across entire populations, but to drill down and examine how groups within the population fare, in order to identify and address disparities in access, quality, or outcomes. This requires examining data by neighborhoods, by racial/ethnic groups, by condition, etc.
Balancing integration and specialization in managed care organizations. A distinctive component of the new Medicaid managed care system will be the development of “Health and Recovery Plans.” These “lines of business” within existing managed care plans are being designed to achieve 2 important goals: (a) to create entities responsible for care that address all their enrollees’ needs, including both physical health and behavioral health, while (b) maintaining a specialized expertise and focus on the unique needs of people with serious mental illnesses and substance use disorders. HARPs are due to begin operations in New York City in January 2015. We believe that HARPs will be models for how managed care plans can effectively organize and pay for services and can work with government to build a more robust, less fragmented system. A particular challenge for New York City around reducing fragmentation is managing the complexity of a system that serves such a large population. When there are multiple health plans and HARPs, interacting with several Health Homes, all interacting with large and overlapping networks of providers and a variety of government-run systems, the goal of seamlessness seems daunting. Health information systems and information exchange will be critical ingredients of an integrated, interconnected system. More broadly, we need to find ways at all levels of the system – care, care coordination, and care management organizations – to proactively and continuously engage consumers and leverage all the resources of our complex system.
Providing the most effective services to all who may benefit from them. An ongoing challenge in health care generally, and behavioral health in particular, is to provide the best, scientifically validated practices to all those who need them. This was a motivation behind adding the so-called “1915i” services, such as crisis respite, employment, peer services, and family support, to the Medicaid service package. We will be focused on how the emerging components of this transformed system will support and expand consumers’ access to best practices. For example, the Patient Outcomes Research Team (PORT) recommendations for what works in helping consumers with schizophrenia manage their illness and work toward recovery include several components that go well beyond prescribing antipsychotic medications: assertive community treatment, substance use disorder treatment, cognitive-behavioral therapy, supported employment, skills training, family-based services, and weight management interventions. Studies have shown that most people with schizophrenia are not receiving all these potentially beneficial services. How will HARPs and other managed care plans and Health Home care coordinators and service providers assist all patients who need and want these evidence-based practices to receive them? How will the system expand specialized models that serve individuals early in the course of illness? Another example is medication-assisted treatment for opioid dependence. We in New York City are experiencing dramatic increases in the number of people using and becoming dependent on opioids – whether prescription painkillers or heroin. The most effective treatment for opioid dependence involves medications such as methadone and buprenorphine, coupled with counseling. We estimate that as many as half of those who may benefit from treatment are not receiving it. How will the new system expand capacity and access?
Improving how behavioral health is addressed in primary care. While much worthy attention is being placed on improving the system of care for those with the most serious behavioral health conditions, we must keep in mind that the MRT Workgroup rightly called for improvements in how our medical system identifies and helps manage mental health and substance use problems more broadly. Such conditions—depression, anxiety disorders, alcohol and drug misuse—are very common, and poorly addressed, in primary care. When we at the New York City Health Department examined the leading causes of poor health in our city, we found that depression and alcohol use were two of the top four. Primary care practice is undergoing its own transformation to better manage chronic conditions like diabetes and cardiovascular disease. This transformation into “patient-centered medical homes” entails increasing use of health information technology, standardized screening and management protocols, team-based care that includes counseling and support services for patients, and specialty consultation when needed. These are the necessary components for effective depression and substance use care as well. Expectations for behavioral health outcomes should be integrated into primary-care oriented managed care performance monitoring, and clinical providers should be supported in developing behavioral-health-specific capacity, such as collaborative care for depression, screening and brief intervention for alcohol use, and buprenorphine prescribing for opioid dependence.
The New York City Department of Health and Mental Hygiene has been, and will continue to be, an enthusiastic partner with our State colleagues in charting a course for our system’s transformation. We will also be vigilant in monitoring progress toward our shared goals specifically for the people of New York City. The complexity of this task is immense, but so is the potential to benefit the people we serve.