Q&A with Jason Helgerson on Health and Hospitals

Q: What are some of the challenges that the state faces while implementing reforms with the $8 billion federal Medicaid waiver?
JH: The biggest challenge is what we’re asking providers to do to come together in large groupings, sort of across the entire continuum of healthcare—hospitals, clinics, nursing homes, home care providers and specialty providers in behavioral health developed for those who are developmentally disabled. You name it, we’re asking all of these providers to come together and work as a team. Throughout the history of healthcare in New York and across the country, providers have functioned in silos and, in many cases, have seen each other as competitors even though in a lot cases they see the same patients. They can keep the revenue, they can keep their patients and what we’re asking them to do now with [the Delivery System Reform Incentive Payment program] is to work together and be held collectively accountable for improving health outcomes for Medicaid members and that is not easy.

Q: Part of this effort are the “Performing Provider Systems.” What are these?
JH: Many months have been spent trying to create what we call Performing Provider Systems, which is this grouping of providers who will be held accountable for results, and that has been a major challenge. So, I would say that the biggest challenge is trying to get all these different providers— at the minimum it’s hundreds, or over a hundred, and at maximum it’s thousands—providers who are single providers in a system to work together as a team. I would say that’s the biggest challenge.

Q: But the argument is that in the long run this will be the most financially beneficial outcome for these groups, right?
JH: Correct. What I would argue is that healthcare in New York, particularly the safety net element of it, is on a downward slope and what I would use as my evidence for that is diminishing margins, particularly in places like hospitals and nursing homes. And unless we change the path they’re on, there’s going to be a continuous sort of decline and that decline will mean poorer performance by the providers and less access for patients and what we’re trying to do with DSRIP is sort of change that trajectory. What we’re saying is that in the long run these providers—when they work together and when we fundamentally change how we pay for healthcare in ways that will reward providers for their success and allow them to capture savings when they’re successful—that that will lead to a more sustainable future.

Q: Are there any other big policy initiatives or issues involving Medicaid in New York that you expect to come up this year?
JH: Move No. 1 is the fully-integrated dual advantage program, which is trying to bring together—this would be in New York City, Long Island and Westchester County—a pilot project that we’re working on with Medicare where Medicare and Medicaid payments are brought together systematically for the first time. Then we have managed care plans, which will be responsible for the holistic needs of that high-needs population. The second move that’s big is the nursing home benefit has now been carved into managed care contracts effective Feb. 1. And this is a big move—that’s $6 billion of fee-for-service spending that, over time, will move from fee-for-service to managed care. And the last big piece, which we’re particularly excited about, is the $7 billion in behavioral health services to spend outside of managed care and fee-for-service, while the population itself has been mostly in managed care. So we’re carving those services in and asking the managed care companies to be accountable for meeting the complete needs of the Medicaid population, including the most specialized services. But we’re also launching—the first in the nation—a specialized managed care product for people with significant persistent mental illness, as well as a subset of those who have substance abuse disorders. Those will be, as I say, a highly specialized product uniquely designed to meet the needs of that subset of the population.