Managing Expectations

Gov. Andrew Cuomo’s Medicaid Redesign Team has reduced government spending, slowed rising healthcare costs and freed up funds to help struggling hospitals.

But one reform—the shift to managed care programs—is still “making lots of people nervous,” said Assemblyman Richard Gottfried, the longtime chair of the Assembly Health Committee and a member of Cuomo’s Redesign Team.

More than four million Medicaid consumers have been moved to care management programs over the last two years as a result of the Medicaid Redesign Team’s recommendations. The “Care Management for All” initiative, just one aspect of the much larger statewide Medicaid overhaul, calls for 95 percent of Medicaid recipients to be enrolled in care management plans by 2018.

The New York State Department of Health has said that the initiative, which aims to improve coordination of benefits, quality of care and patient outcomes, will shift Medicaid spending to a system under which a managed care organization is paid by the state to organize patient care and reimburse healthcare service providers. This will almost entirely replace fee-for-service Medicaid, under which service providers bill the state directly, patients receive fragmented care and there is less accountability for outcomes.

The initiative aligns with the primary goal of the MRT: to control Medicaid costs by promoting healthy Medicaid patients rather than simply cutting benefits or reducing payment rates. Taken together, MRT initiatives are already projected to reduce Medicaid spending growth by billions of dollars.

Managed care organizations—or, in some cases, a health management organization, or HMO—will be closely regulated and monitored by the state. But providers have raised concerns, including in the mental health field, where the bulk of the patient population has yet to be shifted over to the new plans.

“It’s all supposed to start in 2015,” said Glenn Liebman, CEO of the Mental Health Association in New York State. “At this point we’re trying to figure out where the points are where we can really advocate strongly

to ensure that the best practices and policies are in place for those individuals with psychiatric disabilities, and that they don’t fall through the cracks. Our biggest concern is that there are enough protections in place for those individuals.”

The quality strategy for the Medicaid Managed Care Program, released in the fall of 2012, details managed care organization requirements and a variety of quality assurance metrics that closely compare and monitor compliance and outcomes, ensure patient access to practitioners and isolate areas to target for improvement or advancement.

Currently, however, only a limited range of behavioral health services are available under the program, and advocates see a need for additional regulations addressing the unique demands of those with psychiatric disabilities, as well as a necessity for better training and more behavioral health experience for those who coordinate care. The DOH has acknowledged a need to require organizations to have “extensive experience” managing care for individuals with complex behavioral health issues. Mental health advocates, however, have often excoriated HMO coordinated healthcare plans for limiting necessary services, neglecting rehabilitation and generally misunderstanding or entirely missing mental health issues.

“The pace of change has been rapid,” said Harvey Rosenthal, executive director of the New York Association of Psychiatric Rehabilitation Services. “And I think that gives people pause. Not all of the details have been figured out. But I’ve been an advocate for 38 years, and I think that the proposals here are groundbreaking—and in many instances are what we’ve long sought.”

Noting that the new system provides more accountability for long-term patient outcomes, Rosenthal acknowledged “some risk” regarding implementation. But Rosenthal and NYAPRS have commended the state for its focus on long-term recovery for mental health patients—as opposed to simply providing stopgap treatment— while also emphasizing the need for flexibility in their care.

The Mental Health Association in New York State has raised other concerns about the implementation of coordinated care for mental health patients in the Medicaid program. The organization has called for a stronger safety net, in addition to the funding available for capitated services for individuals who “fall through the cracks” of the new system. The group also suggests incentives to work with existing providers in an effort to “insure continuity” and improve long-term patient recovery rates and provisions for a 24-hour informational helpline.

“The state is taking all comments very seriously, is my understanding,” Liebman said.

Gottfried expects some agitation from health advocates to adopt a more community-based model where “care coordination is community-and provider-based rather than done through HMOs and insurance companies,” he said. States like North Carolina have successfully moved to a care management system that places coordination directly in the hands of primary care providers, bypassing larger providers and utilizing community networks to advance and improve care, he noted.

“I think this would be better for both consumers and providers as well as the health community at large,” Gottfried said. “I’ve been urging this shift for some time, and I know that the Health Department has been looking at it as well. The benefits here could be potentially enormous.”