Behavioral and physical healthcare in New York State are going through an unprecedented transformation. Medicaid redesign, implementation of a health benefit exchange, a transition from fee-for-service to managed behavioral healthcare, integration of behavioral health with primary healthcare, implementation of health homes, and a variety of additional innovations and transformations are among the most prominent component parts of that transformation. Critical elements of our healthcare system are being transformed at a dizzying pace and will evolve in ways that significantly impact how services are delivered, the outcomes that are achieved, and the level of consumer satisfaction. Integration of behavioral health with primary care is vital to the success of healthcare reform in New York State.
During the first meeting of the Medicaid Re-design Team, an array of stakeholder groups that included consumers, services providers, and payers were given an overview of New York State’s Medicaid program and a mission to transform it to improve health outcomes, make better use of resources, and drive down the cost of care. It was noted at this first Medicaid Re-design Team meeting that New York State spent way more than any other state per capita for healthcare and that, in spite of the significant variance in cost when compared with the rest of the country, we ranked only 26th in health outcomes. Anticipating the obvious question, Department of Health staff came to the meeting prepared with an answer to how we could rank so low when we spent so much: New York State was ranked 50th in un-necessary hospitalizations. It was noted during the discussion about the high cost of un-necessary hospitalizations and other un-necessary use of expensive healthcare services that 80% of the patients who were un-necessarily hospitalized had an untreated substance use disorder and a slightly lesser number had a mental health disorder.
As the Medicaid Redesign Team (MRT) began to grapple with how to improve New York’s Medicaid program, it quickly came to the conclusion that behavioral health experts had to play a major role in the re-design. A MRT Behavioral Health Work Group was formed and asked to provide recommendations that would help the MRT to achieve its goals. Those recommendations have been incorporated into the implementation of re-design. Of paramount concern to workgroup participants was how New York could reduce un-necessary hospitalizations while simultaneously improving health outcomes and consumer satisfaction. Consequently, as New York moves forward with Medicaid re-design, behavioral health services providers are expecting to play a significant role.
With passage of the Affordable Care Act, states were encouraged to establish health benefit exchanges as a marketplace for uninsured persons to get coverage for their healthcare. The New York Coalition for Whole Health, a diverse network of advocates and stakeholders, worked closely with key state government officials to ensure that a comprehensive continuum of behavioral health services was included on the menu of benefits required by the New York State of Health, New York’s newly created health benefit exchange. The New York Coalition for Whole Health’s advocacy efforts were successful and, with recent guidance from the New York Department of Financial Services about implementation of parity for behavioral health services, access to services for substance use and mental health disorders is much improved. New York State of Health enrolled close to a million individuals during its initial enrollment period, giving newly insured persons and their families better access to the behavioral and physical healthcare they need.
Transition from Fee-For-Service to Managed Behavioral Healthcare
With the prevalence of untreated substance use and mental health disorders among persons who have been un-necessarily hospitalized or otherwise used a disproportionate amount of healthcare resources, most typically for a physical health concern, Medicaid re-design is very focused on the delivery and management of behavioral health services. Medicaid re-design will soon transition behavioral health services from a fee-for-service model to managed care. As of January 1, 2015, in NYC and as of July 1, 2015 in the rest of New York State, all Medicaid behavioral health services in will be managed by a health plan or behavioral health organization. The economic and health impact of the failure to treat substance use and mental health disorders has been an unacceptable and unnecessary expenditure of healthcare resources and unacceptable health outcomes. Access to and utilization of treatment for substance use and mental health disorders drives down the unnecessary use of expensive healthcare services and helps to significantly improve health outcomes. Medicaid re-design is counting on the management of behavioral health to drive this improvement of health and behavioral health outcomes and to decrease unnecessary healthcare expenses.
Integration of Behavioral and Physical Healthcare
Less than 20% of persons with substance use disorders ever get treatment for their drinking or drug use. The un-necessary hospitalizations associated with untreated substance use disorders are most frequently for other health conditions that are exacerbated by the addiction. Persons with untreated substance use or mental health disorders frequently experience a decline in their health status when health conditions such as diabetes, heart disease, HIV/AIDS, hepatitis, liver disease, and other chronic diseases also go untreated or when, because of the behavioral health symptoms, the individual is not following recommended physical health treatment protocols. Recent monitoring of inpatient care revealed that in only about 10% of the cases are patients successfully referred to behavioral health services when their untreated behavioral health disorder is identified when they are receiving care for a physical health problem. It was also found that the converse was true. People getting treatment for a behavioral health issue are connected with primary care services in only about 10% of the cases when they have a physical health issue. This disconnect between behavioral and physical health care is a major target of health reform initiatives such as the DSRIP program that is currently being developed across New York State. DSRIP is an excellent example of an initiative that seeks to bridge the disconnect between behavioral and physical health services.
Hospitals, community health centers, health homes, and other primary care practices are all being asked to incorporate behavioral health services into their health services offerings. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is being promoted as a science-based tool that can be easily implemented in healthcare settings with the goal of helping people with untreated substance use disorders to get the treatment they need. The use of mental health peers and certified recovery coaches in emergency departments is another strategy that seeks to connect people with the behavioral healthcare that they need while ensuring that physical health needs are also addressed.
National and state healthcare reform presents a tremendous opportunity to improve public health outcomes, reduce costs, and ensure coverage and access to necessary care for all New Yorkers. Improving the connection between behavioral and physical health services is vital to the improvement of health outcomes. Behavioral health providers working across systems with primary care and in collaboration with health plans and managed care organizations have a unique opportunity to positively influence health outcomes in the months and years ahead if the transformation and reform of healthcare properly recognizes the vital importance of substance use and mental disorders prevention, treatment, and recovery support services.
The New York Association of Alcoholism and Substance Abuse Providers (ASAP) will provide significant attention to issues related to healthcare reform, integration of behavioral health and primary care, and the transition to managed care at our 15th Annual Conference with presenting sponsor, LabCorp, on October 19-22 in Saratoga Springs, New York. Our conference theme, The Vital Role that Community Substance Use Services Play in the Success of Healthcare Reform is intended to encourage participation from behavioral health, health insurance, managed care, health home, primary care, and other professionals who are vital to improving health outcomes in New York State. With the technical assistance of ASAP Corporate Affiliate Members Cohn & Resnick, Millin Associates, SAE & Associates, and Brown & Weinraub, the conference will feature a special luncheon for CEOs and their Executive teams focused on services and business transformation. Please join ASAP and our Platinum Sponsors SAMHSA and Alkermes for this important conference.
New York Association of Alcoholism and Substance Abuse Providers, (ASAP) represents the interests of the largest substance use disorders and problem gambling services system in the United States. Through advocacy at the state and federal levels, ASAP champions the urgent message that substance use disorders and problem gambling are public health issues that can be effectively addressed with adequate resources.
ASAP offers professional development, program development, technical assistance, and community education to strengthen and increase access to prevention, treatment and recovery support services.
ASAP serves as a catalyst for cross-systems collaboration with public health, mental health, criminal justice, juvenile justice, child welfare, and social services policy makers and service providers. We represent the field on numerous policy development and implementation work groups with a regional, statewide and national focus.