|Currents - March/April 2013 - Getting Ready for Federal Health Care Reform in New York: 2013 is a C|
This March marks the third anniversary of the enactment of landmark health care reform legislation by the Congress and President Obama, the Patient Protection and Affordable Care Act of 2010 (or the “Affordable Care Act” or “ACA”.) The law has a dual policy purpose: (1) reforming and expanding access to affordable insurance coverage and (2) reforming health care delivery with an eye toward improving access to services, quality of care, and moderating cost growth.
Provisions of the law have been rolling out since enactment, such as not being dropped or excluded from health insurance because of a pre-existing condition. Major insurance coverage improvements and expansions are becoming available for the uninsured in the coming months, however, there is a lot of work to do to make sure New Yorkers understand their options and make important decisions about them. Social workers will play a critical role as service providers and advocates at the individual client and policy levels.
Up to 1.5 million uninsured New Yorkers are projected to obtain coverage in NY, taking a substantial bite out of the state’s 2.5 million uninsured. These coverage options will be either through Medicaid or private commercial plans, both to be obtained through a new “Health Benefits Exchange” that the state is creating per provisions of the ACA law. The Exchange will be operated by the State Department of Health, in partnership with the Department of Financial Services in New York.
This new Exchange will be a voluntary, one-stop “organized marketplace” for small employer groups (both small businesses, including solo and small group practices, as well as non-profits with less than 50 FTE employees.) All will be pooled together so that premium rates will be comparable to the much lower cost of large group plans, and will qualify for sliding-scale tax credits for up to 50% of premium costs.
In addition, individuals and families who are not covered by their employers will be able to use the Exchange to obtain coverage. They will be screened for public health insurance programs first, and then move on to private options. The general Medicaid eligibility level will be raised to 138% of the Federal Poverty Level (FPL), and above that level, people below 400% FPL will qualify for sliding-scale premium subsidies to enroll in a private plan, with sliding-scale limits on annual out-of-pocket costs.
Private plans on the Exchange will be offered on four “metal” tiers (bronze, silver, gold, and platinum), depending on “actuarial value” (industry-speak for the “cost-risk” for an “average patient” paid by the policyholder in premiums vs. deductibles vs. co-pays/co-insurance, as opposed to the risk the plan itself must absorb.) All plans will at minimum conform to a “benchmark” benefit plan used by the state. In the plan in New York is the largest small group plan in the state by enrollment (offered by Oxford), with some benefit enhancements to meet the ACA law’s standards. All plans will cover 10 mandatory benefit areas, with some flexibility around amount, duration, and scope of services allowed. Among the benefit categories are mental health and substance abuse treatment, and there is full mental health parity (meaning these services will be covered in the same way as medical/physical health services.)
Getting more than one million New Yorkers’ aware of what’s going to soon be available and getting enrolled in a health plan through this new Exchange will be a very daunting task for patients and their families. This will require leadership from the State in partnerships with health care and social service professionals and institutions. The time table is as follows: NYS plans to launch a major public relations campaign in the summer; the Exchange will open for enrollment on Oct. 1st, and coverage will begin on January 1, 2014. An open enrollment period will continue through March 31, 2014.
The State will be offering funding and training to entities, brokers, and other individuals to be certified as “navigators” and “in-person assistors” to help people learn their options, make decisions, and get enrolled. Social workers no doubt can and will be part of this process in many settings and NASW will identify in the future ways that social workers can take an active role.
Our national NASW has much useful information on its website about the ACA and how its implementation is proceeding nationally (http://www.naswdc.org/practice/health/default.asp) and in the states to help NASW members prepare and become involved. In addition, both NASW-NYC and NASW-NYS are members of Health Care for All New York and Medicaid Matters New York, two statewide consumer advocacy coalitions focusing on the ACA in New York. Also, NASW-NYS’s Karen Moran serves on the Exchange’s Regional Advisory Committee for the Capital District and Mid-Hudson region. Overall, advocates are urging and assisting the state to develop the most robust and consumer-friendly exchange possible. The shared goal is that everyone can hit the ground running come October 1st and we can get as many uninsured as possible enrolled by the end of next March. The goal is “Cover Everyone – One Million Plus!”
Here in NYC, our local health care justice coalition, the Metro New York Health Care for All Campaign (www.metrohealthcare.org), will be a locus for ongoing public education and advocacy. NASW-NYC has had a seat on Metro’s Steering Committee since its founding in 1995 represented by Dr. Terry Mizrahi. In addition, plans are in the works for NASW-NYC to sponsor a forum later this spring to help social workers and other advocates learn more about the ACA for themselves, their colleagues, and clients in the months ahead.
New York State Medicaid Reform in Behavioral Health
Peter Beitchman, DSW, LMSW, CEO, The Bridge
With dizzying speed (within two months) the MRT produced 79 recommendations for immediate legislative action to restructure the Medicaid system, impacting all service sectors.
Behavioral health costs and quality emerged quickly as a primary MRT focus. High-cost Medicaid users with serious mental illness and/or chemical dependency were identified as using $6.3 billion of services annually, accounting for one-quarter of all expenditures of high cost individuals. Overall, behavioral health expenditures exceeded $8 billion for all Medicaid recipients.
In addition to high costs, behavioral health services were singled out as not producing measurable outcomes. MRT materials pointed to the fee-for-service behavioral health system as one that promotes utilization without measuring impact. The MRT also found a perilous lack of integration between behavioral and medical care services, leading to a premature death rate among people with serious mental illness, anywhere from 15 to 25 years younger compared to the general population.
The fate of behavioral health services during early MRT deliberations seemed uncertain. There was a strong suggestion that to remedy cost, quality and integration concerns the best strategy would be to move behavioral health services into the managed care system immediately. A host of consumer, provider and advocacy organizations objected to this approach, stressing that any transition to managed care would pose a number of serious challenges. Most generally the advocates stressed that the behavioral health system, created over a period of more than 50 years, would not integrate well since managed care companies lacked experience in working with the population and viewed people with serious behavioral issues as an adverse business population. It was argued that the behavioral health system contained many specialty services specifically tailored to the needs of people with serious behavioral conditions that might not fit well into a managed care environment.
A compromise was stuck as embodied in MRT recommendation #93. The recommendation envisioned that over a period of a few years behavioral and medical healthcare would be integrated in a managed care format. While the pieces were put in place behavioral health service would continue in a fee-for-service format for a period of two years, to be replaced by specialty entities that would provide high-need behavioral health recipients with fully managed behavioral and medical care services.
As a step toward managed care, a number of regional Behavioral Health Organizations (BHOs) were created (in New York City the BHO is Optum Health), to monitor lengths of stay of inpatient psychiatric hospitalizations and chemical detoxifications and rehospitalizations following discharge. BHOs were also to be concerned with the transition from inpatient to outpatient behavioral services.
The initial MRT recommendations also contained pure revenue items impacting on behavioral health services. A tiered reimbursement structure designed to reduce spending was put in place for both OMH-licensed mental health clinics and OASAS-licensed outpatient 822 programs. Under this initiative, reimbursement rates are reduced when recipients receive more than 30 visits a year and again should they receive more than 50 visits a year. These revenue actions were in addition to the then-recent restructuring of rates that were already raising concerns about the financial viability of some clinic programs.
Creating “Health Homes”
One of the signal initiatives emanating from the MRT has been the creation of Health Homes – care coordination programs for high-need/high-cost Medicaid recipients, including persons with serious mental illness and chemical dependence. Although Health Homes only provide care coordination services to integrate behavioral, medical and social services, they include defined networks of service providers, including primary care, behavioral health, hospital, long-term care and related providers. Originally envisioned as serving more than 700,000 individuals statewide, the implementation of Health Homes has been much slower than anticipated. In Brooklyn and the Bronx, where both community-based and hospital-based Health Homes have been created, they are serving relatively small numbers. Health Homes in Manhattan, Queens and Staten Island are just being launched.
A Major Shift for Providers
The MRT created a Behavioral Health Workgroup, again comprised of a variety of stakeholders. Its initial deliberations lasted for six months, followed by a Final Recommendations report. The report strongly endorsed the integration of behavioral and medical care services and envisions a managed care environment, with payment for services tied to recipient outcomes. One of the major insights of the report, and a finding embraced by the MRT, is the importance of housing in stabilizing the lives of people with serious behavioral health conditions. In each of the past two years, despite flat or reduced funding in most behavioral health programs, significant new funding has been appropriated to develop housing.
Housing and Children’s Mental Health
One of the areas that has been particularly challenging and in which little progress has been made is children’s mental health. A separate sub-group was created to address children’s issues, which pose significant challenges in view of the multiple systems involved in the provision of services – formal mental health services, schools, child welfare agencies, the legal system and families. Health Homes for children have yet to be developed and recommendations for the basic structure of a future children’s behavioral health system have yet to be developed.
Recently, in the context of the Governor’s proposed budget for the fiscal year that begins on April 1st, some elements of the long-range plans for behavioral health have come into sharper focus. First, the vision of managed care is reaffirmed and strengthened. Whereas originally the MRT envisioned the creation of independent Full-Benefit Special Needs Plans to be the payer of managed integrated behavioral and healthcare services, this idea has morphed to Health and Recovery Plans (HARPS), which are now defined as “lines of business” within a managed care organization. While the implications of this change are not fully understood, advocates are concerned that this may imply a structure with less essential government oversight.
Outpatient Clinics and Long Term Care
Another proposal in the Governor’s budget would end the current reimbursement rates for mental health and OASAS clinic services in 2015. The implication here is that when managed care is fully implemented rates will be deregulated in such a way that individual providers will have to negotiate individually with managed care companies, a process that is likely to drive reimbursement rates lower.
There are other aspects of Medicaid reform that will also impact on behavioral health recipients. Managed Long-Term Care Plans and specialized managed care plans for dual-eligible Medicaid/Medicare recipients are also being developed (up to one-third of people with serious behavioral conditions fall into the dual-eligible category).
Question of Which Services Will Be Included
Other serious concerns remain. What services will be included in the behavioral health service package that managed care companies will be required to fund? Of special concern on the mental health side is the PROS Program (Personalized Recovery-Oriented Service) which is the core rehabilitation program for persons with serious mental illness. Since PROS is a mid- to long-term program for its participants, advocates are concerned about how it will fit into managed care.
The questions of transparency and government oversight are in the forefront. It is essential that spending on behavioral health services be tracked separately in the managed care system to assure that services continue to be available. And government must play a role in defining the minimum amount of the managed care dollar that must be spent on direct services, the so-called “stop-loss” ratio. Managed care companies’ concern for their financial bottom line can cut both ways: while it is true that wellness and prevention are important values, the fear that services might be rationed is a concern to all involved in behavioral health services. If the vision of integrated health and behavioral health results in overall savings, there must be a formula to reinvest savings in behavioral services. Only through such reinvestment will behavioral health providers and consumers continue to develop the innovative services that will keep pace with developments in the field.
Also undetermined is the role of local government in a managed care environment. The City Department if Health and Mental Hygiene has played an essential role not only in contracting and monitoring services, but also working with providers, consumers and families to identify gaps in services, including in communities of color and ethnic communities.
Challenges for Social Workers
As Medicaid reform continues to roll-out, those social workers who practice in the behavioral health arena will face new challenges. The focus on integrated services, spanning behavioral, medical care and social services will require new knowledge and skills. Relating to managed care companies as gatekeepers and being able to demonstrate positive outcomes are two demands of the emerging system that will also challenge us. The changes that are occurring are momentous; in the short-run we have a significant advocacy role to play. With more than 50 years of experience in providing life-sustaining and enhancing behavioral health services, social workers have the knowledge and experience that must inform the reform process to assure that our clients’ interests are well-served in the emerging system.
• Delivering 2/3 of all mental health services in next decade
Social workers who have been in the field for some time may remember when hospital social work departments were downsized due to budget cuts, and many social worke staff were replaced by nurses in areas such as discharge planning. More recent budget cuts to public service programs and community-based organizations have caused new concern among many professionals about both their ability to retain positions in their own organizations and the future of the profession.
1 The White House. (n.d.). The Obama Administration and Community Health Centers. Retrieved from http://www.whitehouse.gov/sites/default/files/05-01-12_community_health_center_report.pdf
2 National Committee for Quality Assurance. (n.d.). Retrieved from NCQA: www.ncqa.org
3 Agency for Healthcare Research and Quality. Experts call for integrating mental health into primary care. Retrieved from U.S. Department of Health & Human Services: http://www.ahrq.gov/research/jan12/0112RA1.htm
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