New York State Care Management for High Need High Cost Populations Presented by: Greg Allen, Director of Financial Planning and Policy New York State DOH.

New York State Care Management for High Need High Cost Populations

Presented by:Greg Allen, Director of Financial Planning and PolicyNew York State DOH October 26, 2011

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"It is of compelling public importance that the State

conduct a fundamental restructuring of its Medicaid

program to achieve measurable improvement in

health outcomes, sustainable cost control and a

more efficient administrative structure."

- Governor Andrew M. Cuomo, January 5, 2011

Governor’s Vision for Reform

MRT Phase IMajor Reform Elements

(1) Global Medicaid Cap Two-year state share actual dollar cap.

Four-year state share spending cap linked to growth in CPI-Medical.

Industry challenge to control costs.

“Super powers” established to ensure that cap is not exceeded.

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(2) Care Management for All Begins three-year phase-in to access to “care

management for all” Medicaid members.

New York is getting out of the fee-for-service (FFS) business.

Over the next three years, new models of care management will be developed to ensure that special populations obtain the services they need (i.e., self-direction).

Over the next three to five years, develop more “fully-integrated” care management models. 5

(3) Major Expansion of PCMH and Launch of Health HomesUp to one million New York Medicaid

members could be enrolled in PCMHs or Health Homes.

Health Homes will be more expansive than PCMH and will target high-need/high-cost populations.

PCMH and Health Homes will be fully-integrated with care management.

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Integrated Care Management for All

Vision for the Future

Care Management for AllThe MRT has set New York on a multi-year path

to care management for all.

Care management for all is not traditional mandatory managed care in which states rely solely on insurance companies.

New York’s vision is that virtually every member of the Medicaid program will be enrolled in some kind of care management organization.

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Care Management for AllSome care management organizations will

be traditional insurance companies while others will be provider-based plans uniquely designed to meet the needs of special populations.

New York sees full capitation as its preferred financial arrangement but is open to other financing systems, especially for special populations.

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Care Management for AllNew York realizes that a period of transition

is necessary to achieve its ultimate goal of fully-integrated care management for the entire Medicaid program.

Fully-integrated means that a single care management organization would be responsible for managing the complete needs of the member (acute, long-term and behavioral care).

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Care Management for AllIt will take more than three years to reach this

final destination and existing care management organizations will need to evolve while new organizations will need to be created.

New York will use a wide range of care management tools including BHOs, existing health plans, managed long-term care plans and special needs plans to ensure it reaches its goal of eliminating FFS Medicaid within three years.

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Care Management Evolution Cycle

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COMMON QUESTION: How do Health Homes, PCMHs, and other Phase I strategies

fit within Care Management for All?

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Managed Care

PCMH

IDS

ACO

Health Home

BHO

Care Management for All The Vision

Medicaid and Dual Population 5 million

Mainstream HMO

RiskManagement Approach

Sub population

High Needs/High Cost

Duals/Non-Duals

Children/Families

Childless Adults

Partial Benefit

Mainstream HMO

Non Long Term Care

Long Term Care

Mainstream HMO

BH SNP AIDS SNP

Mainstream HMO LTC SNP (former

MLTCP) Possible Other Model

Possible FFS or other TPA

CareManagement Approach

HH

PCMH

IDS/ACO

HH

Self Direct

ed

IDS/ACO

PCMH

ACO

HH PCMH

ACO

HH

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CMS Medicaid Director Letter

“The goal in building “health homes” will be to

expand the traditional medical home models to build

linkages to other community and social supports,

and to enhance coordination of medical and

behavioral health care, in keeping with the needs of

persons with multiple chronic illnesses.”

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• All Other Chronic

Conditions• 306,087

Recipients• $698 PMPM

• Mental Health and/or Substance Abuse

• 408,529 Recipients• $1,370 PMPM

• Long Term Care

• 209,622 Recipients• $4509 PMPM

• Developmental Disabilities

• 52,118 Recipients• $10,429 PMPM

$6.5 Billion50% Dual10% MMC

$10.7 Billion

77% Dual18%

MMC

$2.4 Billion20% Dual

69% MMC

$6.3 Billion16% Dual61% MMC

HH Populations - 2010

$25.9 Billion

Total Complex

N=976,356$2,338 PMPM

32% Dual51% MMC

Out of the Behavioral Health and Chronic (n = 715K) Medical Cohorts in 2009:Just under 74,000 members were 0-20 years

oldApproximately 41,000 were in NYC 38,000 had a primary diagnosis in the Mental

Disorders spectrum

Children and Health Home

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HH Quality MeasuresGoal 3: Improve Outcomes for persons with Mental Illness and/or Substance Use Disorders

Mental Health Utilization(HEDIS 2012 – Use of Services) The number and

percentage of members receiving the following mental health services during the measurement year. Any serviceInpatientIntensive outpatient or partial hospitalizationOutpatient or ED

HH Quality MeasuresGoal 3: Improve Outcomes for persons with Mental Illness and/or Substance Use DisordersFollow Up After Hospitalization for Mental IllnessFollow up After Hospitalization for Alcohol and

Chemical Dependency DetoxificationAntidepressant Medication ManagementFollow Up Care for Children Prescribed ADHD

MedicationAdherence to Antipsychotics for Individuals with

SchizophreniaAdherence to Mood Stabilizers for Individuals with

Bipolar I Disorder

Implementation Status Enrollment target – January 2012 For Phase One

Phase One Counties – Bronx, Brooklyn, Nassau, Monroe, Warren, Washington, Essex, Hamilton, Saratoga, Clinton, Franklin, St. Lawrence, Schenectady

Phase two – April 2012, Phase Three – June 2012

CMS and SAMSHA Consults occurred with State HH Team - DOH, OMH, OASAS and Aids Institute

Working with MRT children’s behavioral health subcommittee and other children’s providers on building health homes that are tailored to the needs of the under 21 population

Draft quality measures have been developed with expert stakeholder group

Draft rates and finance model has been developed with State agencies – revising now based on feedback from expert panel.

Final State Plan submitted – much work up front with CMS on draft SPA.

NYS Health Home Website (links to many relevant materials):

http://nyhealth.gov/health_care/medicaid/program/medicaid_health_homes/index.htm

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Join the Health Home Listserv and get updated health home information. Go to: http://nyhealth.gov/health_care/medicaid/program/medicaid_health_homes/index.htm.

Questions or comments regarding NYS implementation of Health Homes can be directed to [email protected].

Questions?

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