NYS Council Proposals Submitted to MRT portal
February 24, 2020
Many thanks to those NYS Council members who took the time to share your suggestions for MRT proposals with us, including the members of our Board of Directors who participated actively in a process to identify and review additional proposals for consideration.
Below are the proposals we submitted to the MRT 2.0 portal beginning last Thursday and continuing over the weekend.
As always we want to hear your thoughts! Please share your feedback with us. Write to Lauri Cole: lauri@nyscouncil.org. We look forward to hearing from you!
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MRT 2.0 proposals submitted by the NYS Council for Community Behavioral Healthcare
via MRT portal (Submitted on: 2/19, 2/20 and 2/21)
Title: Require DFS to Require Plans to Pay Adequate Rates for Behavioral Health Services
NYS is forced to subsidize inadequate rates paid by private insurers for behavioral health care services. The DFS continues to permit private insurers to pay between 1/3 & 1/2 of the state-set Medicaid rate for the same service delivered by the same individual. This disparity results in undue pressure on the state-set Medicaid rate in order to ensure providers remain viable as they struggle to provide access to care to any New Yorker regardless of insurance status. NYS can save scarce resources by requiring private health insurers to pay fair and adequate rates for mental health / substance use disorder/addiction services offered community-based behavioral health organizations across New York.
Title: MCO Consolidation and Use of Universal Forms/Technology in the Behavioral Health Carve-In
New York State can save scarce resources by consolidating the number of Managed Care Organizations participating in the behavioral health carve-in. Providers are currently required to comply with the unique administrative and programmatic requirements of each and every health plan they work with. In many cases, agencies must navigate the unique requirements of 30-40 different health plans simultaneously. This results in needless but significant spending to hire personnel to manage these competing requirements. The state should restrict the number of plans participating in any one region of the state and require all remaining participating plans to use universal forms and information-sharing platforms. Access to care would be improved as providers get back to their primary function — provision of care (rather than sitting in front of computers filing reams of paper).
Title: Require NYS to Enforce State and Federal Laws and Issue Monetary Fines to Bad Actors
Over the last 3.5 years NYS and specifically the Office of Health Insurance Programs has failed to use many of the enforcement tools at its’ disposal when MCOs willfully deny care or violate the laws regarding timely and full payment of providers for clean claims. While many MCOs and their BHO vendors fail to comply with state laws governing timely and full payment of providers for services rendered, and despite the fact that 20 citations were issued in May, 2019, few if any financial enforcements have been issued against the plans for these behaviors. It is time for the state to exercise its’ power and ensure access to care by issuing meaningful fines to repeat MCO offenders and to terminate contracts with those health plans that have a track record of failing to comply with state laws/state model contract. If the state were to expedite enforcement activities MCOs might finally take responsibility for their actions/the actions of the BHO they hired. The state could collect fines from bad actor MCOs that have likely been getting away with murder, but at the very least have contributed to the financial tipping point many behavioral health providers find themselves at at this time. Providers having to use lines of credit while they wait for massive back payments from MCOs that have already admitted their errors but fail to make adequate reparations in a timely manner is costing the state, and contributing to a financially fragile behavioral health continuum of care. If the contracts between the state and the MCO need to be amended to expedite the process by which the Department issues monetary fines then we suggest the state amend these contracts at once and rid itself once and for all of MCO/BHO bad actors.
Title: Require MCOs to Bring their BHO Responsibilities ‘In-House’
At present New York State is struggling to get ahead of two public health crises that are devastating local communities across the state. The Opioid Epidemic and rising rates of completed suicides in certain populations continue to strain state budgets while community- based organizations struggle to remain fiscally viable and provide access to care in their local communities. There is now ample evidence that the use of BHOs by MCOs participating in the behavioral health carve-in has resulted in decreased access to care in communities where providers are having to wait 3, 6, 9 months and longer to receive reimbursement for wrongfully denied claims. Many if not most BHOs are not having the intended effect of streamlining access to care and objectively balancing the needs of the client against the resources of the provider. Many MCOs have failed to take responsibility for the actions of their BHOs who blatantly break the law and/or the terms of their contract with the state. NYS should require all health plans participating in the BH carve in to bring their BH administrative services ‘in house’. In at least two instances where a health plan started out using a BHO but fired the BHO and brought the service inside, these health plans are now out performing their peers that still employ BHOs. Many MCOs have shown they do not closely supervise their BHO vendor and in doing so, they have contributed to the continued breakdown or demise of the more than a few BH provider organizations. State Model Contract terms should be revised to require that participating health plans bring the BHO service in house. This would save the state valuable resources resulting from decreased premiums paid to plans. It would also improve care by improving the overall financial health of agencies we are currently relying on so heavily to address the needs of local communities struggling to fend off two simultaneous public health crises.
Title: Expedite Review / Approval of In Lieu-of-Services (ILS) Agreements
While the MRT II process will advance many effective models of healthcare and behavioral healthcare delivery to improve care management for beneficiaries with complex health conditions, there will be many strategies that can be developed by providers and MMCOs that can’t be effectuated through this process. In order to advance additional innovations that are not currently covered under the Medicaid State Plan but that could be critical to containing spending growth, DOH should expedite review and approval of in-lieu-of services (ILS) applications, communicating decisions within 90 days of receipt.
Effective July 2016, federal regulations allowed and clarified the use of Cost-Effective Alternative Services, often referred to as ILS. These regulations encourage innovation and promote efficiency and quality by enabling MMCOs to offer their enrollees physical and behavioral health services that are not covered under the Medicaid State Plan. Prior to this, if MMCOs contracted for services outside of the approved Medicaid State Plan, the cost of such “voluntary services” were not included in their MLR, which is a key driver to determining their premium rates. MMCOs may now, as a cost-effective alternative to Medicaid State Plan services and settings, provide MMCO enrollees with alternative services and settings as permitted by regulations and approved by the State.
MMCOs may not contract for ILS without first applying to the State, obtaining State approval, and demonstrating that a number of requirements will be met. The current approval process is very lengthy (some applications have taken upward of 1 1/2 years to approve) and stymies implementation of projects that could quickly improve care and lower costs.
By investing in an expedited review process for innovative projects, NYS would create an opportunity for providers to implement programs that would drive down costs, largely by aiming to keep individuals in their homes and communities and reduce costly facility-based care, and support the State’s goal to reduce Medicaid costs from 6% to 3% and assist in maintaining future trends at or below 3% for FY 22 and 23.
Title: Consolidate and Expand Providers Included in Patient Consent Forms
The current data sharing environment is not conducive to a truly integrated care network that supports upside and downside risk. More specifically, different licensing agencies require different consents, which are burdensome for providers to collect and maintain and burdensome to consumers who are required to share the same information multiple times or read through multiple lengthy and often confusing forms. While the Statewide Health Information Network for New York (SHIN-NY) and Regional Health Information Organizations (RHIOs) were designed to allow for the electronic exchange of clinical information and connect healthcare professionals, in practice, the process to consent consumers is overwhelming and administratively burdensome to consumers and staff responsible for obtaining consent and as result reduces the number of consents received. Further, not all consents include community-based organizations (CBOs) or non-medical providers in the consent, which excludes them from data sharing efforts. As a result of each of these barriers, access to and sharing of data is impeded for all healthcare and service providers whose ultimate goal is to provide comprehensive, integrated, coordinated, and efficient care.
Consolidating and simplifying the consent process and including CBOs or non-medical providers in this consolidated consent would reduce consumer and provider burden and increase consent rates and data sharing efforts. Further, the consolidated consent should include a provision to allow data access and sharing for both historical and future providers participating in the network to minimize the need to re-consent patients on frequent basis (i.e. at each visit). Implementing a process to consolidate and simplify the consent process would require minimal, if any cost, to the State but reduce the costly administrative burden caused by the existing consent process and would go a long way in supporting efficient use of Medicaid dollars related to coordination and management of care among enrollees.
Title: Increase Access to Cost and Outcomes Data for Behavioral Health Providers & Networks
Current state policies and practices related to sharing data with behavioral health providers, non-medical providers (i.e., community-based organizations [CBOs]), or networks of providers (i.e., IPAs) do not facilitate timely data sharing or more often any access to data. For example, existing value-based payment (VBP) contracts center on primary medical care and as such, data related to accessibility, provider capacity, and access to and utilization of behavioral health services among attributed consumers within these networks are unknown. While Behavioral Health Care Collaboratives (BHCCs) have requested this from NYS DOH, it has not been shared. In addition, Medicaid Managed Care (MMC) plans are not required to share outcomes and cost data with potential VBP contractors or provider groups. However, this data is critical to enable non-primary medical providers to develop informed proposals for alternative payment arrangements. Finally, under DSRIP, Performing Provider Systems (PPSs) received funding to develop regional data analytic capacity but BHCCs and other non-medical providers have had uneven experience with PPSs in accessing data relevant to their work. Proposed VBP Roadmap language regarding this matter ‘strongly encourages’, but does not require, the sharing of data with providers who may not be lead entities.
Although behavioral health makes up only a few percentage points of the overall Medicaid spend, the behavioral health population makes up a significant portion of the overall spend when their medical care is considered. Meeting the behavioral health and social determinant of health needs of this population in the community provides an opportunity to reduce their reliance on more expensive acute, institutional-based care.
The MRT should advance a recommendation to expand access to the Master Medicaid Data Warehouse for BHCCs and other non-medical providers and include a data sharing requirement in future contracts with MMC plans and PPSs or VMOs. The State should amend the proposed VBP Roadmap language to include specifics as to what information/data must be shared and what constitutes timely sharing of this information. These changes would ensure timely access to cost and quality data, supporting entities participating in VBP and alternative payment models to minimize adverse outcomes that might increase risk and vulnerability.