Transcript Managed Care - Mental Health America

MHA Issues Forum
March 6, 2013
Harvey Rosenthal www.nyaprs.org
THE OPPORTUNITIES FOR RECOVERY AND
PEER SERVICES IN NYS HEALTHCARE REFORM
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BACKDROP TO HEALTHCARE REFORM
EXPECTATIONS PREDICT OUTCOMES

People with ‘serious’ mental health conditions
will have life long struggles:
 Will
be in clinic, day and housing programs for all of
their lives
 Will regularly relapse and require emergency and
hospital readmissions
 Will be on a range of powerful medications
 Will never work = poverty, entitlements
 Will not engage easily/be non-compliant and
require mandated treatment
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THE COST TO PEOPLE AND TAXPAYERS
People are poor, idle, isolated, segregated…lack
hope, purpose and community.
 People have ‘chronic conditions’, dying 15-25
years earlier due to higher rates of obesity,
diabetes, lung and cardiovascular diseases
 Federal, state and local governments spend huge
amounts of public funds on healthcare funding
lifelong services to people w ‘chronic conditions’
 NYS: $54 billion Medicaid program; $8.7 billion
behavioral health system; homeless, CJ costs

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THE PERFECT STORM
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Financial: governments can’t afford to continue to fund
uncoordinated, inefficient, costly services that don’t
encourage wellness rather than ‘chronicity’
Affordable Care Act/NYS Medicaid Redesign: coordinated,
active, engaging, accountable, integrated outcome oriented
person centered
Managed Care: flexibility and interest in funding peer
services, social determinants
Olmstead: emphasis on most integrated supports vs.
institutional services (hospitals, nursing/adult homes,
sheltered workshops, day programs (?)
Consumer & Recovery Movements: choice, rights, wellness,
community integration, life beyond services, alternatives
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THE NEED FOR HEALTHCARE REFORM
NYS EXAMPLE
New York’s Medicaid program serves almost 5
million beneficiaries at a cost of about $54
billion annually.
 20% of Medicaid beneficiaries use almost
80% of the money, 40% have BH diagnoses.


Hospital, emergency room, medications, services
NY spent the most in avoidable readmissions
($800m); 70% have BH diagnoses, 3/5 of
these admissions are for medical reasons
 15% unemployment, high homelessness rates

Lots of $ Spent, Very Poor Outcomes
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NYS MEDICAID REDESIGN PLAN
Integrating services to work in a more
coordinated, collaborative and accountable
fashion through federally incentivized health
home networks
 Integrating health, pharmacy, mental health
and addiction services under managed care
 Rewarding outcomes vs paying for visits
 Consolidating Medicaid under the Department
of Health
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WHAT ARE HEALTH HOMES?
A health home is a ‘hub’ not a house
 Health homes are multidisciplinary teams
comprised of medical, mental health, and
addiction treatment providers and social
services organizations who work together to
improve care and reduce costs for those with
more serious ongoing conditions

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HEALTH HOME NETWORK LEADER
 Health
home lead agencies provide:
 Dedicated
care managers who assure that
enrollees receive all needed medical, behavioral,
and social services from their assembled networks
of treatment, housing and social services
 in accordance with a single care management plan
 that is shared with all providers via an electronic
healthcare record
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HEATH HOMES GOAL

Health homes are accountable for reducing
avoidable health care costs, specifically
preventable hospital admissions/readmissions,
skilled nursing facility admissions and
emergency room visits and meeting quality
measures.
 Active
engagement
 24-7 response
 Focus on well coordinated discharge and treatment
planning
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HEALTH HOME FUNDING
Health home leaders get a monthly rate for
each person served that pays for care
management, electronic health care record
system and administrative costs.
 Health home network members continue to bill
existing funding streams….until we move to
managed care.
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HUDSON RIVER HEALTHCARE
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Hospitals: Good Samaritan Hospital; Hudson Valley Hospital
Center; St. Francis Hospital and Health Centers; St. John's
Riverside Hospital; Vassar Brothers Medical Center
Health Plans: Hudson Health Plan
Medical Providers: Health Quest Medical Practice;
Healthcare Opportunities Provided with Excellence (HOPE)
Center; Institute for Family Health
Misc: Arms Acres; AIDS Related Community Services (ARCS);
Hudson River Housing; St. Christopher's Inn; Sullivan County
Department of Community Services; Taconic Health
Information Network and Community (THINC RHIO); Together
Our Unity Can Heal, housing, social , disability services
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HUDSON RIVER HEALTHCARE
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BH Providers: Dutchess County Department of Mental
Hygiene; Hudson Valley Mental Health; Human
Development Services of Westchester; Lexington Center
for Recovery; Mental Health America of Dutchess
County; Mental Health Association of Westchester;
Mental Health Association of Rockland; Occupations;
Putnam Family and Children's Services; Rehabilitation
Support Services; Rockland County Department of
Mental Health; The Recovery Center; Gateway
Community Industries; Westchester Jewish Community
Services (WJCS); Westchester County Department of
Community Mental Health;
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WHY JOIN A HEALTH HOME?
CONSUMERS
Integrated Care
 Help with Navigating the Health Care System
 Better Access
 Better Coordination
 Wellness and Person Centered
 Focus on Skills to Stay Healthy
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WHY JOIN A HEALTH HOME NETWORK?
PROVIDERS
Part of an Integrated Care Team
 Access to Referrals
 Electronic Data Sharing
 To Get Connected to the Future
 Outcome Focused and Accountable
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WHY JOIN A HEALTH HOME NETWORK?
PROVIDERS

Positioned for Managed Care
 Health
Homes are Organizing Networks Which Will
Contract with MC
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Behavioral health providers bring vital services
to networks, e.g., care management,
rehabilitation and recovery services, skills in
engagement and motivation, housing,
employment, peer staff, treatment
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PEER SERVICES IN HEALTH HOMES
 Health
homes can re-program care
management dollars to buy peer
services that can promote:
Outreach
and engagement
Hospital/Prison/AH to community
transitional support/bridging
Wellness self management support
Crisis diversion and relapse prevention
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PEER SERVICES IN HEALTH HOMES
 Sample
arrangement…working in
subcontract with a health home to be part
of a ‘service triangle’:
Care manager
Nurse
Peer wellness coach/navigator:
outreach, engagement, service
planning, coaching, diversion, advocacy
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FROM FEE FOR SERVICE TO MANAGED CARE
Some states are preparing to ‘carve in’ Medicaid
behavioral health services, turning them over to
the coordination of managed health insurance
plans .
 Plans will be paid on a ‘capitated’ per person per
month basis for outcomes not visits.
 Plans will authorize payments to contracted
providers and networks based on their success in
engaging and serving beneficiaries….and reducing
avoidable costs.
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OUR OPPORTUNITY IN MANAGED CARE
 Managed
care companies and BHOs have
great flexibility beyond traditional Medicaid
rules and more narrow medical necessity
restrictions to buy approved non traditional
services that are proven to work, if the state’s
design expects, rewards and enforces those
values.
 States can expect and even require managed
care to buy peer services…especially if it’s in
the request for proposals and contracts
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MANAGED CARE HAS THE FLEXIBILITY TO BUY
…IF IT’S IN THE RFP AND CONTRACT

Social determinants of health
Employment supports and benefits advisement
 Housing relocation start up costs
 Culturally competent outreach and engagement

Peer services
 Clubhouse services
 Crisis services
 Self directed budgets: emergency housing
supports, health club memberships,
computer/internet, alternatives
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PLANS USING PEER SERVICES
OptumHealth: peer bridgers in Wisconsin,
Tennessee, New York, New Mexico; peer warm
line, crisis respite and bridgers in Washington
 Magellan: self directed care program in
Pennsylvania; crisis alternatives in Arizona;
psychiatric rehabilitation in Iowa
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PLANS USING PEER SERVICES
Community Care: recovery institute, learning
collaborative, supported housing reinvestment;
consumer/family satisfaction teams
 ValueOptions: self directed care program in
Texas, peer services and consumer research
and evaluation in Massachusetts
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Health plans are becoming interested too.
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OTHER NEW PAYERS
Accountable Care Organizations
 Medicaid/Medicare Demonstration Programs
 Hospitals
 Medical providers
 Mental health and addiction service providers
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Subcontracts are key to preserving integrity
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NEW ROLES, GROUPS FOR PEER SERVICES
From a rights protection, advocacy and
empowerment focus for people within the
mental health system to…
 Bringing hope, wellness, resilience and rights
protections to a broader array of people (preSSI and private insurance beneficiaries) as a
part of the greater healthcare system
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BEYOND PEER SPECIALISTS
EXAMPLES OF SPECIALTY SERVICES
Peer Bridging
 Peer Crisis Diversion: warm lines, respite house
 Peer Wellness Coaching/Navigator
 Rights Protection & Advocacy: Ombuds
 Life Coaching: work, economic self sufficiency
 Peer Supported Housing
Services not Programs
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DATA IS KEY
SOME NYS EXAMPLES
2010 study: Rose House crisis respite guests
did not return to hospital in the following two
years
 NYAPRS Peer Bridger program helped support a
72% drop in OMH hospital & a 50% drop in
Optum Medicaid hospital readmissions/days
 2010 Optum Health Peer Link reduced hospital
days by 71% in Wisconsin, by 41% in Tennessee
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DATA IS KEY
SOME NYS EXAMPLES
2010: Mental Health Peer Connection’s Life
Coaches helped 53% of individuals with
employment goals to successfully return to
work
 2011: Housing Options Made Easy helped 70%
of residents to successfully stay out of hospital
in the following year
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DATA IS KEY
PEER WELLNESS COACHING: ONE PERSON’S OUTCOMES
•
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Required persistent engagement, recovery
and relapse prevention support, health
coaching and re-connection to benefits
2009-prior to enrollment: 7 inpt stays (4
different facilities) $52,282
2010-1 detox, 1 rehab (referred by the
CIDP team) $20,650.
2011 relapse with detox/rehab
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PEER SERVICES CAN PLAY A CRUCIAL ROLE…
If we’re prepared to play an effective and
transformative role in the healthcare system
 If we’re successful in getting state government,
managed care and health homes to value us
and include us as desirable if not mandatory
benefits people are offered
 If we can manage new requirements re liability,
cash flow, documentation, privacy protections,
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PEER SERVICES CAN PLAY A CRUCIAL ROLE…
If we can describe in clear terms our services,
methods, outcomes and costs..and make the
business care for our services
 If we’re prepared to define and meet training
and professional standards
 If we can promote and protect the integrity of
true peer support and peer run agencies
 If we can promote self directed budgets and
alternatives, based on our success in HCR
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STATE LEVEL ADVOCACY NEEDED
Services must promote recovery and wellness,
health literacy and ‘self management’
 Beneficiaries must be guaranteed Informed
choice, privacy and other basic rights
protections, supported by peer advocates
and/or enrollment brokers, with consumer
access to personal electronic records that
prominently features advance directives.
 There must be significant reinvestment of
Medicaid savings into peer services, housing,
rehabilitation/ employment services expansion.
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STATE LEVEL ADVOCACY NEEDED
Peer run services should play prominent
roles in BHO, health homes and managed
care re-designs.
 Open access to medications of choice
 Crucial importance of cultural competence
and other strategies to address health
disparities
 Inclusion of 1915.i self direction and flexible
recovery services in HARPs
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STATE LEVEL ADVOCACY NEEDED
Outcomes: Beyond Days To Outpatient
and Medication Use
Cultural and linguistic competence,
engagement and diversion
 Use of peer services
 Reduced mortality and health disparities
 Reduced criminal and juvenile justice
involvement (diversion, re-entry?)
 Reduction in use of court-ordered
outpatient treatment
 Improved care transitions
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NEXUS BETWEEN PEER SUPPORT, HEALTHCARE
AND BUDGET REFORM AND OLMSTEAD
We’ve come from being
ahead of our time to being
right on time…if we raise
the bar on our service
design/delivery/marketing
and our advocacy!
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