"Meeting Challenges: Trying to Stay One Step Ahead"

Steve HansonAssociate Commissioner

Treatment & Practice Innovation

“ The times, they are a-changing” - Bob

Dylan

What’s Changing in Treatment?

Almost Everything!• Substances being used• Models for Treatment• Managing Care• Insurance Coverage• Payment Mechanisms• Performance Measures

Substances Being Used

• Alcohol, Cocaine, Marijuana,• Opiates – Heroin & Prescription• Designer Drugs

2011 National Survey on Drug Use and Health (NSDUH),

2011 National Survey on Drug Use and Health (NSDUH),

2011 National Survey on Drug Use and Health (NSDUH),

OASAS - 2011 Treatment System Fast Facts

2011 National Survey on Drug Use and Health (NSDUH),

2011 National Survey on Drug Use and Health (NSDUH),

2011 National Survey on Drug Use and Health (NSDUH),

2011 National Survey on Drug Use and Health (NSDUH),

Designer Drugs• Round 1 – ’60’s and ’70’s -

hallucinogens• Round 2 – ’80’s and ‘90’s – synthetic

opiates and MDMA (ecstasy) variations

• Round 3 – Now – synthetic cannabinoids and the “Bath Salt” family.

• www.Erowid.org

Designer Drugs• Take advantage of drug laws to

make a “new” drug that is legal• Make a drug that is “better” than

current• Avoid detection• Landscape changes quickly

Lab-Based Drug Testing (2010):

Lab Testing 2012

Analog Prevalence 2010

Analog Prevalence - 2012

Managed Care

Historic System• Fee for Service Medicaid – Patients frequently

use Emergency Rooms as primary provider. No one responsible for well being of patient.

• Uninsured – State funding (including Federal Block Grant dollars) for people without insurance or services not covered by Medicaid (e.g. Intensive Residential)

• Programs covered by “net deficit” reimbursement.

• Historic system consisted of high cost, frequently ineffective care for many.

2010 Detox Top 1000 Users

$159 million76%

$11 million5%

$39 million19%

Top 1000.3%

Next 9003.1%

Remaining27,81296.5%

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One Person in 201073 Detox Admissions

291 Detox Days

15 Detox Providers

Over $300,000 Cost

It is Time to ChangeOh, DarnWas thatToday?

BHO Phase II• All Medicaid Covered Lives have managed

behavioral healthcare.• Offices (OASAS, OMH, DOH, NYC DOHMH)

working to develop model for Medicaid management.

• Implementation 2014• Working with Mercer consulting firm

– Design questions– Population/actuarials– Rate setting– Network Designs

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It’s ComplicatedIssues:• Structures/Models• NYC and ROS• Waivers• CMS requirements• Eligibility• Enrollment• Actuarials• Benefits• Adults and Kids• Etc., Etc….

State Funded Care• Coverage of uninsured individuals • Coverage for non-Medicaid Reimbursable Care• “Net-Deficit” Funding• SAMHSA – Federal Block grant dollars should be

“managed”• Commissioner’s priority that a Pay for

Performance system of reimbursement be instituted.

• Hold providers accountable for outcomes.• In development.

Impact on Criminal Justice System

• Increased focus on treatment outcomes should improve CJ system outcomes for individuals receiving CD treatment services.

• OASAS working on LOCADTR-3. Level of care determination tool. What level of care is appropriate.

• Concern about CJ clients being placed in higher level treatment programs for “Public Safety” issues rather than clinical necessity.

Inpatient

Rehab

OutpatientRehab

IntensiveResidential

PROVIDERS IN THE MIDDLE

Medicaid Managed Care

• “Medical Necessity” Standard• Risk factors based on Substance

– High – Opiates – Overdose Risk Substantial

– Medium – Alcohol/Cocaine – Some OD risk

– Low – Marijuana- No OD Risk

Appropriate Levels of Care• Money is tight – Federal/State

budgets• Federal Block Grant changes• Expectations on Performance and

Outcomes• Level of Care must be determined by

Treatment, not CJ, using accepted standards – ASAM, LOCADTR-3

Improving Performance

• Governor/Commissioner’s Goals of Improving outcomes for patients

• Federal goals of performance improvement for Block Grant

• Identifying good outcome measures

61.3% 54.7%

46.3%

26.9%

Adverse Discharges

Pay for Performance

• Current “Net Deficit” funding mechanism does not address program outcomes.

• System to “pay for performance” under development

Treatment Models

• NY has utilized treatment models that are somewhat different than the rest of the country.

• US Median IR LOS for Treatment Complete – 90 days

• NY Median IR LOS for Treatment Complete – 189 days (221 with Transfers)

OASAS Goals

• Review Treatment models to ensure:– Best Outcomes– Appropriate Care– Reasonable Length of Stay– Program Accountability