Medicaid in New York: Innovating in an Era of Uncertainty

New York State's Medicaid program is one of the most far-reaching in the nation—which leaves it particularly vulnerable to the potential cutbacks debated in Congress this summer. Nevertheless, New York Medicaid director Jason Helgerson told attendees at UHF's 2017 Medicaid Conference that the state is more committed than ever to its long-standing goal of building a Medicaid system that delivers better outcomes at a lower cost, all while serving a larger and more diverse population than ever before. His call to action: “To survive uncertainty, we must continue to innovate, and become more efficient.”

Almost 60 percent of New York's children between birth and age 3 are covered by Medicaid, he said, giving the state a unique opportunity to address social determinants that can impact a young child's lifelong health—such as poverty, lack of access to healthy food and safe play spaces, housing insecurity, and exposure to stress and violence. “If we do a better job of trying to influence the lives of our youngest children, we can prevent so much cost, so much misery, so many problems in the future,” Mr. Helgerson said.

The program will bring together stakeholders from across the state and this fall will roll out a 10-point plan to improve access to services and outcomes for children during their first three years.

(From left) Jim Tallon, Jason Helgerson, and Chad Shearer
(From left) Jim Tallon, Jason Helgerson, and Chad Shearer

Other strategic priorities for the state this year include a continued focus on the Delivery System Reform Incentive Payment (DSRIP) Program and value-based payments (VBP), designed to make Medicaid more efficient and cost-effective. Per-recipient spending in the Medicaid program is currently at its lowest in more than a decade, Mr. Helgerson said. Now, “we have to work collectively to ensure this performance continues to improve.”

New challenges are also rising from the changing face of Medicaid, as enrollment in rural parts of the state grows much faster than in urban centers. New York's Medicaid population increased by 26.3 percent from December 2010 to December 2016, with a gain in New York City over that time period of 15.5 percent compared with 45 percent outside of the city, and 37 percent in rural counties.

Mr. Helgerson closed with a call for empathy. “Remember that health care is a ‘humans serving humans' business,” he said. Providers and policymakers must think about how patients view and experience the care they receive. “Demonstrating empathy can help providers understand and appreciate complex circumstances facing their patients. Empathy can also be used to engage patients in their own treatment plans and improve outcomes.”

Panelists for a discussion on addressing the behavioral health needs of diverse Medicaid populations talked about the relatively smooth transition over the last two years from fee-for-service to managed care plans for behavioral health services for Medicaid-eligible adults in New York. A year from now, children with behavioral health issues will also be enrolled in managed care plans, and in 2019, children in foster care will be included. The panelists agreed that the inclusion of children will bring a unique set of issues; providers will need to develop systems for treating the family as a unit, for example.

Moderator Andy Cleek, deputy director, System Change Initiatives, McSilver Institute for Poverty Policy and Research, New York University, said 85 percent of Medicaid enrollees receiving behavioral health treatments should be in value-based payment arrangements by 2020, and the state has committed $60 million in funding over three years to help community-based behavioral health implement partnerships that will support this goal. This effort is about improving care as much as it is about payment reform, he said. Ultimately, behavioral health should be fully integrated in the health care system.

(From left) Andrew F. Cleek, Robert Hayes, Debbie Pantin, John Kastan, and Jorge Petit
(From left) Andrew F. Cleek, Robert Hayes, Debbie Pantin, John Kastan, and Jorge Petit

The move to managed care is still working through some issues, however. Robert Hayes, President and CEO, Community Healthcare Network, discussed the need to better integrate behavioral health services into primary care practices. At Community Health Network, primary care physicians wanted psychiatric providers in their health center to provide support for tough cases and advice for those of lesser difficulty, with the ability to hand off the most difficult cases when necessary. There is also a need for greater flexibility; and maintaining mission focus and stability in the face of relentless performance standards required by Medicaid.

John Kastan, chief program officer, Jewish Board of Family and Children's Services, noted that, for community organizations transitioning to managed care, maintaining organizational stability and mission focus while dealing with relentless performance pressures is challenging, particularly since reimbursements can also be slower due to additional state requirements. Medicaid populations are often spread across many different plans, adding to the complexity.

Deborah Pantin, CEO, VIP Community Services, outlined some of the staffing challenges faced by her organization in the move to integrate behavioral health treatments: Increased overdose prevention training, extended admission hours, certified enrollment specialists, new payment procedures and infrastructure; all mixed in with staffing shortages. For his part, Dr. Jorge Petit, regional senior vice president, New York market, Beacon Health Options, explored the role of the payer in the managed care model. Beacon Health Options handles about 30 percent of the Medicaid behavioral health business in New York, but few members are receiving integrated home- and community-based services while in health and recovery plans (HARPs), he said. Beacon is currently pursuing three preferred designs with a goal of three to four pilots across the state: transition of care to large outpatient providers; capitation rates for substance abuse disorder providers; and working with plan partners to share savings from addressing total medical expenses for the HARP population.

The ongoing Delivery System Reform Incentive Payment (DSRIP) program and the move to value-based payments were the focus of a thought provoking afternoon panel discussion. The state is in the third demonstration year of DSRIP, a mechanism for restructuring the health care delivery system with the goal of reducing avoidable hospital use by 25 percent over five years. The final years of the program also coincide with New York's transition to value-based payments in Medicaid. “DSRIP has shaken the health care DNA of New York,” said Peggy Chan, DSRIP director at the New York State Department of Health (NYSDOH).

(From left) Chad Shearer, Peggy Chan, Irene Kaufman, Susan Beane, and Niyum Gandhi
(From left) Chad Shearer, Peggy Chan, Irene Kaufman, Susan Beane, and Niyum Gandhi

At NYSDOH, 45 action teams with over 400 staff members are addressing the highest users of hospital services, and one of their greatest needs is more data. “The state can provide trended data from a year ago, at best,” said Ms. Chan. Problems with data security and HIPAA restrictions are making it difficult for the department to collect and analyze the information they need to determine the factors driving hospital use. Bronx Partners for Healthy Communities (BHPC) also needs better patient tracking data, said Irene Kauffman, BHPC's executive director. The targets set by the state are challenging, and providers are still learning to work in a more coordinated fashion.

Dr. Susan Beane, vice-president and medical director, Healthfirst, celebrated the progress made under DSRIP, with managed care organizations working with Performing Provider Systems (PPSs) in ways that are improving outcomes. She called, however, for increased focus on prevention, which requires stronger community partnerships addressing the upstream social determinants of health. Niyum Ghandi, executive vice president and chief population health officer, Mount Sinai Health System, noted that DSRIP is providing opportunities to better serve vulnerable populations. However, he cautioned that “transformation is the most overused word in health care. Not everything is actually transformational.” There may be an intent to change everything, and a few sites will be completely redesigned, but many of these “transformations” are not scalable.

Jim Tallon
Jim Tallon

UHF President Jim Tallon wrapped up the conference with a look back and forward at Medicaid as he prepares to retire later this summer. “Medicaid is the health care component of our public assistance programs,” Mr. Tallon said. “People think this is a program for women and children, but the expenditures are dominated by the elderly and disabled—kids and adults are only 35 percent of expenditures.”

Mr. Tallon has been involved with Medicaid in New York since its inception in 1966, and recounted New York's bipartisan dedication to a robust program, despite numerous threats over the decades. The pressure continues, Mr. Tallon said, and there are now two very different views in Washington of how to make Medicaid sustainable: one side wants to get more healthy people into the risk pool, by expanding eligibility, while the other wants to reduce the numbers of sick people in the pool.

Presentations from the conference can be downloaded here.

Aug. 9, 2017
Focus Area
Clinical-Community PartnershipsQuality and EfficiencyCoverage and Access
Medicaid Institute