Mental Health News is very pleased to present you with our recent interview with Jason A. Helgerson, Medicaid Director of New York State, and Executive Director of New York’s Medicaid Redesign Team. New York’s Medicaid program provides vital health care services to over 5 million New Yorkers and has an annual budget in excess of $54 billion. In addition, as Executive Director of New York’s Medicaid Redesign Team (MRT), Jason is leading Governor Cuomo’s effort to fundamentally reshape the state’s Medicaid program in order to both lower costs and improve health care quality.
Q: Thank you for speaking with us about many of the sweeping reforms now taking place throughout NYS under your leadership. How can Medicaid Redesign address the need to integrate medical and behavioral health services and enhance the quality of life for people with mental illness and substance use disorders?
A: We have heard over and over again throughout the MRT process how we need to more effectively integrate the medical and behavioral health needs of people who receive their health care through Medicaid. We also have learned about the need to break down the different silos within NYS’s health care system which many feel have led to poor patient outcomes and higher program costs. These silos have a history of not being able to communicate with each other or work together, and information is not being shared between them. As a result, fragile individuals are falling through the cracks, their quality of life is declining, and the programs caring for them are incurring costs way beyond what can be achieved by creating a more integrated service delivery system.
The key to integrating medical and behavioral health services and enhancing the quality of life for people with mental illness and substance use issues are at the cornerstone of our new and emerging Health Homes initiative. Developing Health Homes are at the forefront of our effort to bring together disparate groups of providers. These providers have historically viewed each other as competitors rather than partners and have not necessarily shared information with each other, even though they have all touched some of our most complex patients in one way, shape, or form. We are bringing those groups together to form Health Homes which will be responsible for coordinating care and managing the needs of some of Medicaid’s most complex patients, including people with serious behavioral health needs.
We think there’s a tremendous opportunity here. The current system has not served this population well and Health Homes are a means and a strategy to integrate the medical and behavioral health services.
Q: Can you explain to our readers exactly what Health Homes are and how the average consumer of mental health or substance use services will access and experience them?
A: Good question. With regard to Health Homes, we hope consumers will first receive a mailing sent directly to them by one of our Health Homes to let them know there is a new set of services for which they are eligible. The Health Homes will let consumers know about the range of services that will be offered to them and the kinds of coordination/assistance the Health Home can provide to them. The consumer will then decide whether or not they wish to participate–it is not a mandatory program. We hope the individuals that will be told about their options to join will see the value of it.
On the managed care side, we hope to have a number of plans from which individuals can choose – some highly specialized and others more general in nature. Our goal is to make this as seamless a transition as possible. Our goal is to create a host of health-care choices for folks to choose from.
Q: What will become of all the mental health and substance use provider agencies and organizations that are currently providing all the services now available to consumers today?
A: There will continue to be providers. What we have been trying to do is to bring the agencies together and to integrate them into Health Homes – because they continue to be vital providers. One way the behavioral health provider community will directly benefit from Health Homes will come from our ability to provide them with the funds necessary to develop electronic records for the sharing of information. These funds have until now been only available to primary care providers and hospitals.
Q: Currently, behavioral health services for people with serious mental illness and substance use disorders in NYS are “carved out” of managed care. The Medicaid Redesign Team vision is to fold these services into managed care. Given the high utilization of services in these populations, how do you address the concern that a managed care structure may result in the rationing of services?
A: The other area we are going to be looking to integrate (still a work in progress) is trying to find ways to get those services into more effective management – to also try to integrate those services effectively with the acute care/physical health side but not to do it in a way that leads to a draining of resources away from behavioral health. That’s always been the concern within the behavioral health community around carving in the services into mainstream managed care – that services would no longer be available or no longer be provided. Where we’ve been going on the managed care front is moving forward with contracting with behavioral health organizations initially with a set of management services but eventually on capitation and then also looking to find ways to integrate those behavioral health organizations and get them working together with both Health Homes as well as the mainstream plans.
The other integration technique we are really excited about are Special Needs Plans, particularly in high-density areas like New York City – we’ll be able to create specialized, fully integrated managed care plans that are uniquely situated to manage the complex needs of people with significant behavioral health challenges. These Special Needs Plans would manage the physical health as well as the behavioral health needs. We have done this successfully in New York for people with Aids and HIV and we think we can replicate this strategy which holds a lot of promise of both achieving true integration and at the same time making integration is being done by an organizations that have the expertise to manage the population.
Q: In recent years the mental health system has increasingly embraced the concept of “recovery,” which envisions recipients achieving independence in multiple spheres of their lives, including: housing, employment, education, etc. In what ways will the current reforms in NYS promote recovery as a major goal in consumer’s lives?
A: Absolutely, we are working very closely with our colleagues at the NYS Office of Mental Health. Commissioner Michael Hogan speaks often about the need to make sure all of our strategies focus on moving people towards recovery. In terms of recovery, the MRT has now had to take a look at things like housing which was not on our radar screens when we began designing the new reforms back in January of 2011. Housing has now become a vital part of our current plan, thanks to the advocacy of a lot of different folks throughout the mental health community of NYS. We learned from them the importance of housing in the recovery process. Stable housing, for many of our highest needs Medicaid patients is the number one impediment to their getting well. What we need to do is to look to use the Medicaid programs (to the extent to which we are allowed) and partnering with funds from other programs to further expand access to supportive housing. We are very interested in trying to use Medicaid as a progressive force for expanding access to housing options.
Q: Can MRT funding be used to invest in vital services like supportive housing?
A: The first step of the MRT plan had initial funding of $75 million dollars. We also have approval for an exciting initiative that allows us to create and capture savings as we close institutional settings such as nursing homes or other types of underutilized settings this year and plug these captured savings back into things like adding addition supportive housing units next year. The big next step is that we are pursuing a Medicaid Waiver Amendment to allow us to be able to reinvest some of the Federal savings we are generating by all of our efforts – then to reinvest some of those dollars into supportive housing and other housing options. The total value of our “ask” to the Federal government for the Waiver is $2 billion dollars per year over 5 years for a total of $10 billion dollars. There is significant opportunity for us then to invest in vital services like supported housing.
Q: The behavioral health system includes both hospitals and nonprofit community-based agencies. Continuity of care between these two systems continues to be a serious problem. Does the Medicaid Redesign Team have a strategy to address this issue?
A: Continuity of care has yet to be addressed. This relates to quite a few strategies such as making sure patients coming out of inpatient psychiatric stays have an effective care plan that reconnects them with community-based services. That is phase one of the behavioral health organization’s efforts. A key fundamental measure of the success of that initiative will be the degree to which those plans make sure that within their network there is strong collaboration and partnership between the hospitals and the community-based agencies. Lastly the Health Homes – that’s what they are all about – are to build those relationships across a wide array of providers – including all the agencies and organizations that see these same individuals now for only a small piece of their total health care needs. Our goal is to bring all that effort together community by community with the Health Homes initiative.
Let me speak a bit more about the nature of a Health Home. Each Health Home is a little bit different. We have so far certified thirty-four Health Homes all across New York State. There are about three thousand people already enrolled in Health Homes. A Health Home is like an Accountable Care Organization (ACO) for very high-needs individuals – because it is more holistic and comprehensive than a traditional ACO which is very much the medical model.
Q: Is the Health Home housed in a physical location that consumers will go to for assistance, or is it simply a 1-800 number people will call to speak with a case manager?
A: The Health Home consists of actual people helping consumers across NYS. Depending on their level of acuity, every individual who uses a Health Home will have a case manager to work who has a case load of individuals who they are responsible for. Very high acuity level individuals will have a caseworker with a very low case load – like ten to one. In quite a few cases, the Health Home has an actual physical office location. The overall idea is that all of the organizations within the Health Homes (30 or more in some cases) that consumers may frequent will all have access to that consumer’s entire health and medical records. They will know who your doctors are and what services you are connected with – so when they see or speak with you, they can help you with information that is shared within the Health Home partners. Everyone is connected in a single point of entry system that can help the individual consumer in a much more comprehensive fashion.
Q: If for example a mental health or substance use consumer is having difficulty with their medication not working for them, how will their Health Home worker remedy the situation?
A: The Health Home workers will connect that consumer back with their psychiatrist or primary care physician to help you navigate the system to get you what you need. It will be different than it is now, where in many cases consumers with significant needs have to visit multiple sites to receive help and those entities are not connected in any way. Our hope is that by providing the new integrated service and getting people what they need, this will hopefully reduce the likelihood that they will need to use an emergency room, and reduce the likelihood that they will need to be admitted to an inpatient psychiatric stay.
The interesting thing is that for people with significant behavioral health needs, the major expense in caring for them is not for their behavioral health needs, but rather for their physical health needs. Somebody with significant and persistent mental illness who also has diabetes, hypertension, COPD – when they are not being effectively treated for their depression or their schizophrenia, they are not able to take care of themselves with regards to their other physical health conditions. What ends up happening and the reason they are getting admitted is because their diabetes is completely out of control or because of their COPD related breathing difficulties, they are ending up in extended stay hospitals. When you draw back the real root cause of why their health is in such terrible shape – it’s because they have a behavioral health challenge that’s not being addressed.
What I like to tell people is that for a lot of the patients that we are working with through the new Health Homes – we’re going to be spending more money on the behavioral health side to make sure they are on the medications they need to be on and we’re getting them whatever other form of treatment that they need. This greater expenditure on the behavioral health side will save us money down the line in fewer hospital admissions.
Q: Years ago, behavioral health consumers were placed in continuing day-treatment programs (CDT’s) where they had a place to go every day for treatment and support, rather than stay isolated in their SRO or supportive housing apartment. With the new sweeping reforms and Health Home models coming about, will consumers have a place to go every day to help them feel connected to a caring community?
A: I think you’re right. There have been reductions in funding for far too many of the behavioral health programs over the years due to budget constraints here in NYS and nationally throughout the mental health community. A lot of that was a result of how we pay for things. In a fee-for-service world, we had a host of programs of various types which we continued to cut funding back on, to the point where providers were no longer able to provide them. What happened was a result of having a very narrow view of budgets – where you end up cutting things that in reality ended up cutting costs (in some cases) at the other end of programs. The way things were budgeted wasn’t dynamic enough to show those costs elsewhere in the system – and as a result we made penny-wise pound-foolish decisions at the end of the day.
Let’s look at some of the advantages of capitation and managed care in the long run. Let’s assume we can get all of our complex patients into managed care organizations that are competent to manage the complete needs of complex patients. By giving the managed care organizations the capitation payment, they will actually have an incentive to try to keep people out of hospitals and other types of settings. This encourages programs to look at lower cost alternatives and why supportive housing and other types of services will be very attractive in that environment because they will help the plans keep their costs down by meeting the needs of the patient. It’s not going to be a silver bullet quick solution to rebuild capacity. We need to look at the budget as a whole and think about the needs of the patients as a whole and then as time goes on the funds and recourses will begin to flow to those services that are most cost effective.
Q: Delivering mental health services to seriously emotionally disturbed children is enormously complicated, involving mental health and health care providers as well as the education and child welfare systems. How does the Medicaid Redesign Team envision structuring children’s mental health services?
A: There are very significant challenges there. The MRT had a work group specifically focused on behavioral health which created its own sub-group on children’s behavioral health issues. That group continues to meet today and is really grappling with the needs of children with significant behavioral health needs – whether they are in foster care or other types of institutional settings. The system that has grown up around them to provide services is fragile and has an antiquated financial system. What we’ve been working on may become a Health Home type solution specifically for children.
The other questions for children with very significant behavioral health needs include: 1) What managed care solution will best meet children’s needs? (2) How do we strengthen delivery systems that provide children with services? and (3) How do we work with this small but important population and what measures do we use to gauge our success in meeting these children’s needs?
To be honest, it remains a very vexing issue for us, but I think we have the right people around the table working on this. We are hoping that in a matter of a few months we will have a much more comprehensive strategy about how to address the needs of this population.
Q: As people with serious mental illness age, their medical needs increase. Does the Medicaid Redesign Team have a vision of how to provide services to older adults who have serious mental illness and co-occurring serious medical conditions?
A: For older adults we think there are some wonderful opportunities. With older adults much of the Medicaid focus tends to be on long-term care service. Obviously for older adults the vast majority of those over the age of 65 are on Medicare as their primary insurer. Very low-income older adults are also enrolled in Medicaid (dual-eligible).
We are rolling out one of our most successful and unique managed care models in the country called the Managed Long-Term Care Program. It focuses on those dually-eligible individuals’ long-term care needs. We recently did a survey of customer satisfaction and found 90% satisfaction with consumers – an unusually high satisfaction rate for a government program, which we feel really good about.
Beginning in 2014, we are going to start integrating Medicare benefits with long-term care Medicaid benefits. In addition, we will also bring in Medicaid funded behavioral health services. We will then have a fully integrated product for older adults receiving in-home and community-based services. We think that by building off this very successful model of bringing those pieces together, looking at the holistic needs of the patient, engaging the consumer, and getting them out into the community we will prevent the kind of isolation so common in this population of older adults. When an older adult does not have family support and only a home aid, they are cut off from the greater community around them and are more prone to depression. We think that a plan to get those individuals into social settings and re-involved in their community is a really exciting project. On the behavioral health side a lot of older adults have an un-diagnosed behavioral health issue. By bringing the behavioral health benefit in, we plan on making that a real part of the assessment that is done for these older adults through the Managed Long-Term Care Program. A very individualized care plan for each older adult will be developed within 30 days of enrollment, where the member and their family have a sit-down face-to-face meeting with the care plan manager to go over the complete needs of that member to put together an individualized care plan. I think we will end up with a highly individualized, highly integrated product for that aging population which is becoming bigger and bigger over time with the aging of the baby-boom generation.
Q: Will there be a monitoring process to keep the new MRT reforms on track and to give periodic report cards on their performance to stakeholders in NYS?
A: Absolutely. The MRT website (http://www.health.ny.gov/health_care/medicaid/redesign/) enables us to be very transparent with stakeholders throughout NYS, not only in the development of our plans which are available for review on our website, but also in monitoring implementation. We are also in the process of putting out an MRT quarterly newsletter on implementation from MRT to give the public a better sense of the direction of programs. On the financial side, we publish a monthly global Medicaid Spending Cap Report. We track our expenditures very carefully. Program-wise for the first time, there will be a series of performance measurers with short, mid and long-term goals for each measure and every year these measurers will be updated on a regular basis. If we see any problems of failure to hit any targets, our intention is to think about what strategies need to be deployed to address the areas where we may be lagging. It’s going to take us a full five years to implement all the initiatives the MRT has been charged to complete, and we’re not going to stop engaging the public throughout this process.
Prior to arriving in New York, Mr. Jason A. Helgerson was Wisconsin’s Medicaid Director. In that capacity, he administered the state’s nationally recognized BadgerCare Plus program for children and families (Wisconsin’s Family Medicaid, SCHIP, and Healthy Start Program); BadgerCare Plus Core Plan; SeniorCare (Pharmacy Plus Waiver); FoodShare (Supplemental Nutrition Assistance Program); and Wisconsin’s Chronic Disease Program.
Jason was also the principle project sponsor for BadgerCare Plus, former Wisconsin Governor Jim Doyle’s signature health care initiative. Through this program, 98% of Wisconsin residents have access to affordable health care, including all children.
Jason served as Executive Assistant/Policy Director to the Secretary of the Wisconsin Department of Health and Family Services (DHFS) from February 2005 to March 2007. Prior to joining DHFS, Jason served as the Executive Assistant for the Wisconsin Department of Revenue.
Prior to joining the Doyle Administration, Jason served as the Senior Education Policy Advisor for Mayor Ron Gonzales of the City of San Jose, CA. In this role, he provided advice and counsel to the Mayor on all issues related to children. Before joining Mayor Gonzales’ staff, Jason worked for the Milwaukee Public Schools (MPS) where he served as both the chief lobbyist for the district and as a deputy budget director. Prior to taking the position with MPS, Jason worked for Milwaukee Mayor John Norquist where he was the Education Policy Advisor and served as a senior official in the Mayor’s Budget Office.
Mental Health News wishes to thank Bill Schwarz, Director, Public Affairs Group at the New York State Department of Health, for arranging our interview with Mr. Helgerson. We would also like to thank Dr. Peter Beitchman, Executive Director of The Bridge, and Chairman of the Mental Health News Board for his assistance in helping us develop many of the questions used in our interview.