2017-18 NYS Council Executive Budget Priorities

Our preliminary list of priorities for 2017-18 includes the items below; however, we are always poised to respond to changing conditions, opportunities, and concerns from our members.

 1.      Workforce Issues

 Challenges:

  • Federal Labor Standards Act (FLSA) = unfunded mandate (postponed but not eliminated).
  • Minimum Wage: Providers compliance to meet compression standards = unfunded mandate.
  • Managed Care companies, hospitals, criminal justice services, etc. attracting talent away from CBOs due to their compensation competitiveness. This has been chronic but now accelerating.
  • Shortages of Psychiatrists, Psychiatric Nurse Practitioners, Social Workers and other licensed and unlicensed staff are (for many providers) at crisis levels. Recovery Coaches, Peer Specialists, etc. are staffing enhancements but do not replace licensed staff with specific knowledge and clinical expertise.  The ongoing Opioid/Heroin Crisis demands availability of staff at all levels of care.
  • MMC billing requirements, DSRIP, VBP, ICD-10 and client population changes all demand staff enhancements in key roles including CFO, HR Director, Coding and Billing Specialists.

Example of anticipated FLSA Impact (when implemented):

  • Review counselor duties and expectations
  • Shadow clinicians working to see what is taking up their time
  • Monitor hours worked and “home access” time for completing paperwork
  • Hire additional administrative support to assist in case coordination and follow up (overhead)
  • Draft new organization chart and positions
  • Identify criteria for being “exempt” and raise to the new threshold
  • Re-define job/duties for those that will be hourly

      Estimated impact to one agency would be $1.5 million/year

One state-identified solution is to incentivize development of regional IPAs to gain leverage in contract negotiations and decrease back office expenses.  We vigorously support this initiative; however, we do not view IPA development as a replacement for system-wide reform.

It is unlikely VBP shared savings will significantly impact provider viability since all participants will lay claim to “savings” and complexity of system, multiple attribution, measurement issues will not work in our favor considering our current positioning.

Additional Solutions:

  • Fund Compression and Step Increases in Medicaid
  • Loan Forgiveness Programs to address most pressing workforce shortages
  • Regional coaching to increase merger, affiliation and consolidation activity; provide consults using existing financial resources allocated to MCTAC and others.
  • Incentivize regional integrated healthcare systems.

 

2.      Infrastructure and Access to Capital

Challenges:

Providers need funds for infrastructure in order to participate in VBP whether as agencies, IPAs or even part of larger systems. Technology to support financial and outcomes analysis is critical in order to deliver on the value proposition of VBP.

Administrative burdens often conflict with supporting greater speeds of change.  For one agency moving a location from one floor to another is taking over 90 days for approval by 3 separate approval bodies (OASAS, DEA, SAMHSA). To effectively compete we need to be more agile.  Regulations must be flexed and the state workforce given new directives that side with urgency.

Solutions:

  • Expand and continue the Statewide Health Facility Transformation funding for community-based providers; Increase opportunities for CBOs to compete for and receive these dollars.
  • Expand and continue the Non Profit Infrastructure Capital Improvement Program to address routine capital improvements that cannot be addressed because operating expenses exceed reimbursement.
  • Create additional VBP pilots. (Most behavioral health providers were unable to participate in the first round of pilots due to use of 2014 as the claims year however many could be included if 2015 or 2016 claims data was used.)
  • Increase availability of capital for projects that directly address Opioid/Heroin Crisis in local communities.

 

3.      Access to Care in Transition and Ongoing Implementation of BH Medicaid Managed Care

Challenges:

Prior enacted state budget language requires a report to the Legislature on the status of Behavioral Health Medicaid Managed Care (BH MMC) implementation along indicators such as continuity of care, network adequacy, access to care, and rate viability. Questions:  Has anyone seen the plan for monitoring and surveillance of these and other critical measures?  Is there a flow chart? Who is responsible, and what activities/tasks are performed?

The State is running a high percent of dollars through the plans for premium and non-premium related activities. When does it become too much concentrated responsibility and power for the plans?  What language exists in contracts to guarantee prompt payment and swift edits to technology to make this happen.

Solutions:

  • Press for federal approval of Model Contract and share draft amended Model Contract with impacted providers.
  • Budget language that defines the amount of time MCOs and Plans have to update their billing systems/make edits in order to comply with changes to rates and to recently passed laws.    Include incentives and disincentives for meeting these requirements in budget language and in the model contract between the state and the plans.
  • Budget language that explicates financial consequences of plan non-compliance with new Substance Use Access to Care and Continuity of Care laws.
  • Meet with plans to reinforce spirit of agreements made and trust but verify. (Failure to put updated Model Contract on the street results in plans refusing to honor requests by providers to update contracts to include language recommended in OMH and OASAS Guidance documents.)

Fulfill the commitment to the children’s system and extend APG government rate payments to CCBHCs (adult and children’s services) until the state completes an updated Outpatient Clinic Financial Stress Test to determine level of financial distress and viability relative to demand around the state.

Require plans that offer CHIP benefits to reimburse at APG government rate (increasingly hearing plans are not paying in a timely way, not paying APG government rate and/or not paying retroactive to start date, Aril 1, 2015.

Explore and capitalize on what we have learned via creation of PPS rate model for CCBHCs.

Release a flow chart that delineates who is responsible for surveillance and monitoring of protective measures such as Network Adequacy, Continuity of Care, Service Penetration, Service Intensity, Rate Viability, etc. during and after the first 90 days of transition to BH MMC.

 

4.      Access to Care (Indigent Care, Commercial Insurance and VAP federal match)

Indigent Care & Vital Access Provider Grants Federal Match

Last year, both one-house bills set aside funds in the event that a federal match deal was not reached in a timely way, leaving impacted providers on the hook.  NYS Council advocacy also requested amending discriminatory language stating no state funds paid to 31 Clinics unless agreement is renewed with CMS.

Update: CMS has disapproved SPAs addressing federal match for reimbursement of uncompensated care for Article 31 Outpatient Clinics as well as VAP grants.  Article 31 Outpatient Clinics have received no reimbursement for services rendered to indigent New Yorkers for two years and discriminatory language in statute prohibiting payment of state share remains in place.

Solutions:

  • Provide a timeline for reimbursement to Article 31 Clinics.
    • Remove discriminatory language from statute.
    • Survey impacted providers to assess financial crisis due to prolonged non-payment and address accordingly to include loans/financial assistance to providers now at risk.

Commercial Insurance

Behavioral health providers continue to shed commercial contracts due to insufficient rates.  In light of the ongoing Heroin/Opioid epidemic NY can ill afford to lose even one opportunity to provide necessary care to those seeking treatment at the moment when they are motivated to receive it.

The Department of Financial Services (DFS) does not appear willing to request the authority to regulate commercial rates despite the strong likelihood that Medicaid rates are subsidizing commercial rates in our sector.

Solutions:

  • Require DFS to survey all Article 31 Outpatient Clinic behavioral health providers regarding availability of services to commercially insured New Yorkers. Populate an Advisory Board to analyze data and make recommendations to the Governor (if necessary) as to how to rectify any access and continuity issues.
  • Enact All Products prohibitions.
  • Conduct hearings to document impact of commercial rate disparity on local communities.
  • Incentivize health plans to participate in voluntary commercial rate leveling initiative.

 

5.  Access to Care / Continuity of Care Issues in Children’s Behavioral Healthcare System

Challenges:

Unmet need, waiting lists, and delayed access to care foster major disruptions in achievement of positive physical, mental and emotional health for New York’s most vulnerable citizens.  Achievement of critical developmental milestones is necessary for children to grow into healthy, productive members of the community.  Services delayed are services denied.

Solutions:

  • Use the $7.5 million invested but unspent in the 2016-17 State Budget and the $30 million built into the base for 2017-18 for capacity expansion of existing children’s behavioral health services.
  • Outpatient clinics must be funded to add staff to meet the demand for new complex trauma assessments, which can result in additional (faster) Health Home placements that will draw down 90% FFP.