Medicaid Managed Care: Rising to the Challenge

Medicaid Managed Care: Rising to the Challenge

By Briana Gilmore, Public Policy and Advocacy Director, NYAPRS

During a recent forum where policy and business leaders met to publically discuss health care reform, Arthur Gianelli from Mt. Sinai hospital said that for the first time “Medicaid is at the vanguard of delivery system reform.” This statement is a sign of a big change in thinking as Medicaid becomes a new beacon of progressive change in New York State (NYS) and across the nation. The current expansions and experiments in our Medicaid program are driving change at every level: from member satisfaction, to service integration, to oversight of insurance companies and to quality incentives.

These changes have been in the spotlight since Governor Cuomo implemented the Medicaid Redesign Team in 2011. The Redesign Team started to engage experts—including consumer advocates—in a process to transform our expensive but low-quality service system.

An article I wrote in the spring edition of NYC Voices introduced integrated Medicaid Managed Care for people with behavioral health needs and a special option called a Health and Recovery Plan (“HARP”). In spring 2015 in NYC, all adult Medicaid recipients who are not dually enrolled in Medicare will start receiving mental health and addiction services through their chosen insurance plan. Members with greater behavioral health needs will be enrolled in a HARP, and will have a personal assessment to determine eligibility for recovery services.

Several challenges remain before the state can successfully implement HARPs and integrated managed care for over seven hundred thousand Medicaid beneficiaries who use behavioral health services. The greatest challenge is arranging effective care management for every HARP recipient.

Care management is the backbone of NYS’ plans for Medicaid redesign, and Health Homes were implemented statewide to meet the challenge of coordinating care for people with mental, substance, and physical health needs. The implementation of Health Home care management has met challenges since the beginning, including low reimbursement rates for care managers and high case loads. Many Health Home beneficiaries have needs that include homelessness, legal implications of criminal justice involvement, and complex health needs that make behavioral health problems harder to manage.

Care managers have worked hard and in some instances have offered successful coordination, but in others have not been able to effectively assist individuals with all of these needs.

The current expectation is that Health Home care managers will provide a detailed assessment for HARP beneficiaries that can translate into a plan of care that may include an integrated set of recovery services. The plan of care will have to be translated to the HARP insurance plan and then coordinated amongst a network of service providers.

Achieving this for all HARP recipients in a timely way will be very complicated, particularly because the Office of Mental Health (OMH) and the Office of Alcoholism and Substance Abuse Services (OASAS) are estimating eighty thousand NYC residents will be eligible for these assessments as soon as the plan is implemented. The complexities around care management must be negotiated between state agencies and HARP plans, in recognition of the barriers within Health Home implementation and the needs of Medicaid recipients.

NYAPRS has been advocating for the recovery-oriented services offered in a HARP—like peer supports, crisis diversion, family caregiver training, non-medical transportation, and supported employment and education—for years, recognizing their ability to keep people leading a full life in the community. The management of these services by insurance companies will be a new approach to behavioral health delivery.

Managed Care Organizations offering HARP services were evaluated with strict criteria from OMH, OASAS, and the Department of Health. They have to meet readiness standards and a feedback process to the state by which they will be evaluated. But they also have to provide access to a range of new services that have never been offered on such a large scale before, and understand social outcomes like employment and education.

The challenges around recovery services aren’t only at the level of the insurance company, but through interactions between provider and beneficiary. “Recovery-orientation” is easy enough to say, but entails far more than adding a new list of services to a program. Training on best practice models and continuous quality assurance in community behavioral health has previously been the responsibility of OMH and OASAS. They may take on this role to a greater degree in our transformed system, or may rely on HARPs to ensure quality service delivery.

In order to meet access needs, new rehabilitation services including crisis respite, supported education, and psychosocial rehab will be provided by some “traditional providers” like clinics. The ability for these providers to understand the nuances of a recovery journey, support that journey effectively, and offer real change to our community members is a future that seems far away from our current delivery system. The system as a whole must create expectations for standardization and quality improvement and then commit to meeting that challenge.

Many genuine and hard-working people who promote recovery are guiding this transformation within state agencies, community programs, and HARP insurance plans, but rising above the complexities and achieving the challenge of recovery-oriented service delivery will be reliant on dedicated partnerships. The protection of Medicaid beneficiary service access and rights throughout this process must be maintained, without allowing the possible pitfalls of change hinder true progress in our mental health and addiction services.