Positioning for the New York State Managed Care Transition

Preparing your leadership and line staff for the “managed care transition,” can seem daunting and perplexing. There is no simple formula that applies to providers in general, or certain types of providers, except in the broadest sense. Rather, it involves a critical assessment of strengths, challenges and opportunities in programmatic, administrative, financial and mission domains. Each of our organizations has a unique set of attributes, some of which likely help position us to move forward into uncharted territory and others which may themselves need to be “managed” in order not to become obstacles to progress.

It is very easy to get caught up in trying to map out every detail of the State’s transition only to have the state change its timetable or the federal government decides to exclude certain services from the State’s plan. Similarly, if you are not used to speaking with payer organizations such as health plans and BHO’s, it is very easy to become confused about what reflects the industry in general and what’s an idiosyncrasy of a particular payer.

Fortunately, while the pace of change seems rapid, the actual changes tend to be more incremental than you might imagine or fear. Complacency, however, is not an adequate response.

If you answer “yes” to one or both of the following questions, it may be a sign that you are not quite ready for the transition:

Do you look at all the changes that are occurring or being planned by government and payers, and say – I don’t quite understand it but I’m sure government will make sure my organization survives? Can you articulate what distinguishes your organization from others that do the same thing you do?

So, get ready!

What follows are some selected activities that any provider organization can carry out to enhance its readiness and ability to embrace new opportunities.

  • Since financing models will change over time, it is important that your finance leadership becomes versed in the various payment models that exist. This includes the current fee for service systems involving CPT codes and APGs, as well as various partial risk approaches including case rates; gain-sharing; and the like. And, they should begin to school themselves on how to manage per member/per month payments.
  • Your program leadership and your quality staff need to be concurrently thinking about the “value propositions” associated with managed care and population health, how that affects the way programs operate, and how you would “sell” them in an outcome-oriented environment. For example, one of the major goals of the State plan (and managed care plans in general) is to reduce unnecessary emergency room and inpatient hospital use while helping clients function in the community as best as they can, with support, if needed. To the extent that your programs have been successful at this, document it, with solid data if possible.
  • Develop approaches to providing “whole person” care to your clients and establish systems to measure and document these activities, including such simple things as improved access. Of particular importance is documenting efforts to integrate services with other healthcare organizations. Over time, there will be the expectation that you will implement models of services integration that require formerly autonomous organizations to work together. This will include identifying the practices and services you employ that support enhanced community tenure for consumers including pre-vocational and vocational services, social supports, housing related supports, and the like. In the NYS Plan, some of these will be included in Medicaid Managed Care in what are called 1915i-like services, referring to a Federal statute.

The more general point here is to look at what you are currently doing. Then, determine the extent to which it positions you to be effective in a care system that is less focused on producing visits, and more focused on measurable outcomes on a range of traditional clinical goals as well as day to day functioning and recovery. Further, your program development focus should be “how can we improve access to services so that they are available to clients when they need them.”

In order to assess where things currently stand in your organization, here are a few things you can do right now:

  • Walk through your agency as a consumer – does the environment and the procedures you have in place reflect your mission and create the kind of atmosphere that make you feel well-served as a consumer? Are there things you would change right now, regardless of how you get paid? Are there practices that seem counter to encouraging a wellness orientation among your clients?
  • Follow a “charge” through the organization. Are you comfortable that your revenue cycle management is efficient and compliant?
  • Meet with a few major referral sources and/or receivers and review protocols and how the changes such as Medicaid managed care expansion, health homes, etc. will affect the referral flow.
  • Among your medical/clinical staff, is there a person-focused collaborative spirit that is collegial and responsive to client needs? Are clinical resources employed rationally, keeping in mind the scope of practice, cost and skills each type of clinician brings to work? Have you considered how peers and non-licensed staff can support service goals?

Because the velocity of change is increasing, planning and performance need to be embedded in day to day leadership, and the organization needs to be more nimble and more responsive to changing imperatives, while retaining a sense of purpose through shared sense of the mission and the values of the organization.

Regardless of the details of the managed care transition, the above actions can help you start your organization on the way.

PSCH is a comprehensive human service agency whose mission is to empower individuals and families with diverse needs to realize their full potential for achieving meaningful goals, guided by principles of independence, wellness, safety and recovery. Serving Queens, Brooklyn, the Bronx and Staten Island, Westchester, Nassau and Suffolk Counties, PSCH (including Peninsula Counseling Center and The Pederson-Krag Center) offers a complete range of integrated services from primary care and clinical diagnoses and treatment, to educational, vocational, residential, rehabilitation, day treatment and family support programs. The PSCH team provides a personalized approach to suit each individual’s needs and goals. We measure success by how well we empower individuals with developmental and mental health disabilities to achieve their highest potential and to enjoy the best possible quality of life as members of their communities.

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