The Future of Behavioral Healthcare in New York State

The future of behavioral healthcare in NYS is promising and full of great opportunity. While we understand that the future of all Medicaid care being managed creates some anxiety for providers, Governor Cuomo’s Medicaid Redesign Team (MRT) recommendations ensured that the NYS behavioral health agencies OASAS and OMH would lead the development of this future managed care system. Today truly is a new day for the addictions field.  Our future will be shaped by ensuring that our vision for addiction and recovery services is strongly recognized as New York begins implementing the national healthcare reform agenda. This will bring us new and exciting opportunities, new partners, new models of care and new challenges that we will need to work together to meet.

A New Vision: Our vision is fully integrated treatment where behavioral health and physical health are valued equally, and patient-directed recovery goals are supported through a comprehensive and accessible service system. We will need to work to ensure this vision drives addiction policy in New York State.

New Opportunities: Federal and State changes through the Affordable Care Act and Governor Cuomo’s Medicaid Redesign Team have and will continue to provide many opportunities to strengthen addiction service and will bring needed addiction screening and intervention to many patients who are currently unidentified and untreated. We have already seen how we can work together and use these opportunities to strengthen addiction services. Together we have already successfully advocated for: (1) Ensuring that addiction services are included in the Essential Benefit Package, (2) Achieving policy to ensure that Mental Health and Substance Abuse services are managed with parity to other health conditions, and (3) Activating a Behavioral Health sub-committee to inform the design of the managed addiction benefit within the overall Medicaid Redesign.

Working Together: Together there is more for us to do and more opportunities to pursue: (A) We need to build on our past success and use new opportunities to secure a place for addiction screening and referral to treatment in the mainstream of health care, (B) We need to ensure that the people on the front lines of the medical system learn to ask the relevant questions and screen for substance abuse. The OASAS Medical Director has been, and will continue to, meet with the medical directors of hospital Emergency Departments and Comprehensive Psychiatric Emergency Departments to continue our progress towards this goal, (C) We will have new opportunities for care coordination, (D) We want everyone we serve to receive good care coordination, a peer to help bridge treatment and recovery, greater recovery supports, and an improved quality of life, (E) We want to reduce expensive hospital stays by getting people into treatment and giving them the support they need to recover, (F) We want to use Care coordination, arriving in the form of Health Homes, to help us save money on crisis admissions and emergency room visits, and (G) We will then reinvest these savings to improve people’s health in the long-term.

The Future with Medicaid Managed Care: As the State moves towards a fully managed Medicaid system, we understand that we have to be careful and provide protections during this transition. So OASAS has, and will, continue to take action to do just that. We succeeded, with inclusion in the final 2013-14 NYS Budget, in putting into place a number of significant transitional protections: (1) First, managed care will have to reimburse providers at established APG rates for two years, (2) Second, they will have to reimburse providers for the services provided by CASACs, and (3) Third, they will have to include providers in their networks when they have a treatment relationship with the patients in their plans.

Additionally, we will make sure that the state segregates and separately tracks behavioral health spending from physical health spending. Most importantly, OASAS will regularly and carefully monitor how the plans manage the SUD benefit.

The transition to a managed system also provides us with opportunities to further develop innovative patient-centered and recovery-oriented services that providers and OASAS have considered for many years but were unable to achieve in a fee for service environment. We will seek approval from the federal Centers for Medicare & Medicaid Services (CMS) to allow providers to treat people outside the four walls of their facility, in recovery-oriented settings in the community. We will seek approval to offer services such as housing support and pre-vocational training for the high-need individuals who frequently use inpatient services. We will also seek approval so that clinical services provided in all treatment settings are reimbursable by Medicaid. That includes clinical services in our Intensive Residential Treatment programs.

We will continue to work with our partners at DOH and OMH to ensure that our patients receive the best possible integrated treatment. We will also have new partners, including: behavioral health organizations; health plans; health homes; and, health and recovery plans. Our new partners may have different vantage points or perspectives, but we all have the same goal of providing patients with access to excellent care. Together with our new partners we will ensure that we achieve our common goal; that patients have access to all of the resources currently available and that we build new services; new models and new opportunities for community-based recovery.

We will have an opportunity to re-design services to fit with a more modern, patient–centered and recovery-oriented continuum of care that is attractive to patients and payers alike. This will require a rethinking of some of our models including the Intensive Residential Treatment model. Our Intensive Residential Treatment programs vary a great deal in terms of length of stay, completion rates, and costs—and in the services they offer. Currently, New York State has one of the largest Intensive Residential Treatment systems in the world.  We certify 6,724 Intensive Residential Treatment beds that admit about 13,000 people a year, for a total cost of $171 million. Let me be clear – I support residential treatment, but I also believe that even the label “Intensive Residential Treatment” does not do justice to our providers – it is a single label for a shifting menu of services and varying client needs.

I believe that our shared vision of a residential treatment model should be that there is an intensive part of the treatment that is focused on stabilization, the phase that occurs when people first enter treatment followed by a rehabilitation phase that focuses more on drug-free life skills development—and finally a reintegration phase that focuses on education and jobs.

As we move forward, we cannot forget that one of our greatest challenges is misunderstanding. Addiction is still seen by many as a failure of will. The public still doesn’t understand that addiction is a medical condition, that it is an extremely common brain disorder that affects nearly 2 million New Yorkers. The clinical and policy implication of this misunderstanding is enormous. We need to confront this misunderstanding together!!!

I know personally from prior experiences the clinical and fiscal challenges that a full transition to managed care will bring. Clinically, plans will need to develop an understanding of our clients and our system. As Commissioner, you continue to share with me, your concerns that commercial managed care insurers have not always understood addiction services and used a medical model that often created a barrier to access to care. To protect the expertise of your clinicians, we are developing a new level-of-care tool, the OASAS LOCATDR 3. We will require Medicaid managed care plans to use LOCATDR 3, so that decisions about medical necessity are driven by clinical judgment. Fiscally, we will have to assess our business models; develop networks and create attractive and innovative services that you can market to plans. OASAS with our partners at OMH and DOH will carefully qualify, monitor and hold accountable the plans that manage the SUD benefit. OASAS will also change the way in which we regulate services to allow the flexibility to thrive in this new day. We understand providers are concerned about this transition and I am telling you that OASAS will continue to do all we can to allow providers to survive and thrive in the new health care world.

Let‘s continue our work together to face the future with optimism and a clear vision. We will cultivate the new opportunities and partnerships, develop new and innovative models to achieve better outcomes and we will face the challenges together that will make addiction treatment stronger. It’s a new day.  And together, as partners, we can make our work even more effective, meaningful, and rewarding.

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