InvisALERT Solutions – ObservSMART

Perspectives on the Transition to Managed Care

The year 2014 will provide opportunities for OASAS and the other behavioral health agencies in New York as we prepare for the transition to Medicaid Managed Care beginning in 2015. The goal of this change is to create a system that provides New Yorkers with fully integrated behavioral health services within a comprehensive, accessible and recovery-oriented system.

I am excited about the transition as I believe we can capitalize on the Medicaid Managed Care experience to move our treatment system from a program-based to a more flexible community-based treatment system focused on person-centered approaches with expansion of recovery support services in all communities in New York State.

We will seek to leverage the experience and efforts of managed care to reduce unnecessary inpatient care and to place patients in the most appropriate setting, which in many instances will be community based.

We will use managed care to reduce the number of Medicaid participants who continually cycle in and out of hospital-based detoxification programs and are never linked to the next level of care or diverted beforehand, where appropriate to do so.

We can use managed care to help us expand the number of providers who offer recovery support services and to broaden the use of peers supports.

As part of our plan, OASAS is seeking federal approval to move to a rehabilitative Medicaid reimbursement model which would allow our certified programs to provide Medicaid reimbursable services outside the four walls of their clinics.

OASAS is also seeking approval for home and community-based recovery support-type services to be Medicaid reimbursable. We will move to a system where Medicaid reimburses for clinical and medical services, regardless of the treatment modality.

For too long we have focused on volume of services to support programs. The move to Medicaid managed care will allow us to focus on patient needs and support for long term recovery.

We will change how patients are treated in our system of care with a new focus on outcomes and value. We will move away from procedure-driven treatment episodes in clinic settings to value- based reimbursement for episodes of care that meet the patients’ needs for long–term success as close to their own community and family as possible.

No longer will we focus on discreet treatment episodes with a narrow focus on substance use disorder care. We will have opportunities to reward programs that offer integrated care that provide for recovery of physical, mental health and social needs of the individual and family.

While I believe that there are tremendous opportunities with the transition, I also have concerns which we must account for. We need to move away from the use by managed care of medical necessity and level of care tools that ask whether a person has failed at outpatient care before they are allowed to access inpatient treatment. There is no clinical foundation for such criteria. This is why OASAS will mandate the use of our new level of care tool or LOCATDR, which is a clinically-driven instrument focused on the needs and risks of the patient.

We will protect reimbursement rates and will require broad provider networks during the transition, so that we enable the new system to develop by allowing providers to show their ability to produce good outcomes.

We will also spend time in 2014 working with providers and managed care plans to provide information and opportunities to network and develop relationships so that when January 2015 rolls around, both stakeholder groups are prepared to operate in the new system.

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