Best Practices in Medicaid - New York
The Center for Health Transformation is inviting leaders from all 50 states to share their transforming solutions for the Medicaid program. In order that key decision-makers and industry leaders from around the country may learn from others' successes, it is our intention to provide this interactive resource for showcasing the most innovative practices in the country. Please note that the following contributions have not been edited by CHT staff and will remain open indefinitely to future updates.
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Consumer-directed care demonstrations (include number of beneficiaries served now and in any expansion plans). And delivering high quality, coordinated, long term care for the disabled and/or the infirm
A. New York State Department of Health
1. Consumer Directed Personal Assistance Program:
The Consumer Directed Personal Assistance Program (CDPAP), operational in New York State since 1995, allows chronically ill and/or physically disabled individuals in need of, or receiving, home care services under the medical assistance program greater flexibility and freedom of choice in obtaining such services while reducing administrative costs. This program offers individuals an alternative to traditional home and community-based services that include personal care services, home health services and private duty nursing. The local department of social services in each district in the State is responsible for determining eligibility for the program, authorizing services that are provided, and maintaining compliance with programmatic requirements.
The program permits participating individuals to arrange and pay for their own home care through a specifically designated payment system that consists of a Fiscal Intermediary that functions as the employer of record. The consumer can receive authorized services from a provider or individual of their choice. The responsibility for the direction of care is assumed by the consumer rather than an external agency or individual. The consumer?s service authorization is based on a strength-based needs assessment which includes a physician?s order and a nursing and social assessment. In 2005, the CDPAP served approximately 7,500 consumers in all local districts of New York State.
2. Home and Community-Based Services Medicaid Waiver for Individuals with Traumatic Brain Injury:
The Home and Community-Based Services Medicaid Waiver for Individuals with Traumatic Brain Injury (HCBS/TBI) has been in operation in New York State since April 1, 1995. The HCBS/TBI waiver was approved as a Home and Community-Based Services Waiver for nursing home eligible individuals with a TBI and is in its 3rd renewal period effective April 1, 2003 ? March 31, 2008. The HCBS/TBI waiver is one component of a comprehensive strategy developed by the New York State Department of Health to assure that New Yorkers with a traumatic brain injury can receive services within New York in the least restrictive setting appropriate to their needs.
To be eligible for the HCBS/TBI waiver an individual must have a diagnosis of TBI or related diagnosis, be eligible for a nursing facility level of care, be enrolled in the Medicaid Program, be between the ages of 18 and 64, be given the choice of living in the community or in a nursing facility, have or establish a living arrangement that meets the individual?s needs and be able to be served in the community with services available under the HCBS/TBI waiver and New York?s Medicaid State Plan. The HCBS/TBI waiver is administered through a network of State contractors, termed Regional Resource Development Centers (RRDC), each covering specific counties throughout the State. The RRDC staff is responsible for a variety of functions including interviewing potential waiver participants, assisting participants to access approved providers, approving Service Plans, reviewing incident reports and maintaining regional budgets for waiver services.
In addition to the services offered under New York?s Medicaid State Plan, HCBS/TBI participants are also able to utilize twelve waiver services. The services offered under the HCBS/TBI waiver are: Service Coordination, Independent Living Skills Training and Development, Structured Day Program, Substance Abuse Programs, Intensive Behavioral Programs, Community Integration Counseling, Home and Community Support Services, Environmental Modifications, Respite Care, Assistive Technology, Transportation and Community Transition Services.
3. Long Term Home Health Care Program:
The Long Term Home Health Care Program (LTHHCP), also known as the Lombardi Program or Nursing Home Without Walls, has been in operation in New York State since April 1, 1978. The LTHHCP was approved as a Home and Community-Based Services Waiver for the aged and disabled effective January 1, 1983 for an initial 3-year period and as such allowed the LTHHCP to expand its package of services available to Medicaid recipients. The LTHHCP waiver (0034.90.R4) is in its 4th renewal period effective January 1, 2004 ? December 31, 2008.
The LTHHCP is a comprehensive coordinated plan of care and services (medical, nursing, rehabilitative and support services) provided in the individual?s home, including an adult care facility other than a shelter, or in the home of a responsible adult to invalid, infirm or disabled individuals of all ages who are medically eligible for placement in a nursing home. This program offers individuals an alternative to institutionalization. A unique feature of the LTHHCP is Case Management. All individuals must receive case management, and may receive a combination of other home care services based on the joint assessment/reassessment of an individual?s needs by the local department of social services (LDSS) and LTHHCP provider and included in the physician approved plan of care every 120 days. The plan of care may include non-waiver services such as nursing, physical therapy, occupational therapy, speech therapy, medical supplies and equipment, homemaking, housekeeping, and home health aide or personal care aide as well as waiver services such as medical social services, nutritional counseling, education, respiratory therapy, home maintenance, home Improvements, social day care including transportation to the social day care service, home delivered and/or congregate meals, moving assistance, personal emergency response system, and respite care in the home or residential nursing facility. Participants must have care costs which are less than the nursing home cost in the county of their residence. Individuals can access this program through a hospital discharge planner, the LDSS, or a Long Term Home Health Care Program provider. The LDSS determines eligibility for the program, must authorize all services that are provided, and monitors compliance with individual care costs. The LTHHCP provider provides case management and coordinates the provision of all services.
4. Care-At-Home Program:
The Care-At-Home Program (CAH) began operation in New York State as a federal model waiver on 12/1/85. Subsequently, the CAH became a home and community based services waiver. The Program is designed to provide medical and related services to families who want to bring their physically disabled children home from a hospital or nursing home. Families who have already brought their child home are also eligible to apply. CAH has 1,000 slots: 600 slots for children who require a skilled facility level of care (maximum Medicaid budget of $9,000/month) and 400 slots for children who require a hospital level of care (maximum Medicaid budget of $14,500/month). CAH is in its third renewal period, 12/1/03-11/30/08. CAH is administered in conjunction with the local departments of social services.
To be eligible for the CAH waivers, the child must be ineligible for Medicaid when parental income and resources are counted and the child must be eligible for Medicaid when the child?s income and resources are counted. In addition, the child must be under 18 years of age; must have had a continuous 30-day hospital stay (in some cases 30 days within a 90-day period); must be determined physically disabled based on the Supplemental Security Income rules; must require the level of care provided in a skilled nursing facility or in a hospital; and must be able to be cared for safely at home and at no greater cost to Medicaid than in the appropriate facility.
Each CAH participant has a plan of care which identifies all the services that the child needs; the frequency and duration of services; who will provide them and available payment sources. The child?s plan of care is comprised of several components: a comprehensive home assessment which list the services and supports needed by the child in the home; the Pediatric Patient Review Instrument which identifies the child?s medical needs; physician?s orders which shows the medical necessity for the services listed; the case management plan which identifies how the child will obtain needed services; and a monthly budget which shows the total hours of each service; the cost of each item and service, and who will pay for each one. The plan of care is the responsibility of the CAH coordinator in each local social services district, the child?s case manager, and the parent, and is updated periodically.
Children in the CAH program are eligible for all State Plan services as well as the following waiver services: case management, respite care and home and vehicle modifications.
B. New York State Office of Mental Retardation & Developmental Disabilities
1. Care-at-Home Model Medicaid Waivers:
NYS OMRDD operates three CAH Medicaid Home and Community Based Waivers under authority granted by section 1915(c) of the Social Security Act. These waivers are considered ?model 200? waivers because they were granted under a special application category for model waivers set up in the early 1980s as a way to obtain expedited federal approval of waivers intended for relatively small state programs that targeted children with disabilities. The NYS Legislature has granted special authority for the operation of Care-at-Home waivers. Two waivers (CAH I and II) are operated directly by New York State Department of Health (discussed above) and are open to all qualifying children with medical complexities. Three waivers (CAH III, IV, and VI) are operated by OMRDD specifically for children who have medical complexities and developmental disabilities. The OMRDD CAH waivers support 600 children. OMRDD's CAH waivers provide for services intended to support children with developmental disabilities and complex medical conditions to live in their own homes with their families and thereby avoid placement in Intermediate Care Facilities for the Developmentally Disabled (ICFs/DD). Children who are enrolled in the waiver are provided with case management services, respite care, and environmental modifications. Most importantly, the waiver authority allows the child to be determined Medicaid eligible without taking into consideration the income or resources of the parents. Medicaid eligibility makes available a wide array of Medicaid State Plan services that address the complex health conditions of these children.
2. Federal Home and Community Based Services (HCBS) Medicaid Waiver:
In September 1991, CMS (then Health Care Financing Administration) approved the Home and Community Based Services waiver in New York State for people with mental retardation or other developmental disabilities. The waiver provided the state with a mechanism to support people in the community who might not otherwise have been eligible for federal financial support. Thus, the state was able to use this administrative tool to provide predictable Medicaid financing for supports and services received in homes and community settings. Since 1991, the waiver has made a significant contribution to New York's dramatic expansion in supports and services, and has been the key to the State's achievement of an individualized service environment for enrolled individuals. As of March 31, 2006, over 56,000 people were enrolled in the HCBS waiver.
When this waiver was initially established in 1991, one of its unique characteristics was its stated intention to reorganize the state's service delivery system to establish an individualized services environment (ISE), for waiver participants. The ISE allows the design of uniquely tailored packages of supports and services that help each person pursue his or her goals in life. Independence and inclusion in the community are primary values in designing these packages, as is the productive use of personal time. These values are rooted in the federal Developmental Disabilities Act, which underscores the importance of individualization, integration, independence and productivity. The ISE now has become the major strategic force that has transformed New York's services. The system formerly dominated by congregate care programs has changed to a flexible resource network that offers a balance between traditional model-based programs and individualized services.
As the developmental disabilities field in general and OMRDD in particular have embraced consumer empowerment and inclusion, the importance of the HCBS waiver has increased. There have been significant increases in the number of people enrolled in the HCBS waiver and living at home. The HCBS waiver has resulted in more people living successfully in the community. As OMRDD has increased its emphasis on person-centered approaches to service planning and delivery, more and more support packages are being tailored to individual needs and desires than are typically offered in model-based programs. The ISE approach has proven to be a powerful organizing principle that results in people being supported in the most integrated setting possible.
OMRDD and the provider community are focused on the personal choices and needs of those among us who have developmental disabilities. Progress is seen in broadening efforts to help people live in homes they choose, including homes they rent or own. Progress is also manifest in burgeoning efforts to help people gain access to jobs, volunteer work and other integrated day activities. The waiver has a consumer self-directed service option called Consolidated Supports and Services, which allows people with disabilities and their families to manage their own budget and hire staff. They work with a Fiscal Employer Agent who makes payments to providers consistent with the consumer directed plan and assists with meeting regulatory and fiscal requirements.
3. Creating Alternatives in Residential Environments and Services (NYS-CARES, NYS-CARES II) and New York State Options for People Through Services (NYS OPTS):
NYS-CARES and NYS OPTS are current examples of bold, innovative ideas that will have broad impact on OMRDD's ability to meet its strategic goals in the years ahead.
a. NYS-CARES - From its inception through March 31, 2005, the NYS-CARES program solved a huge problem for many persons with developmental disabilities and their families who were waiting-in many cases for long periods-for out-of-home residential services. It provided more than 12,000 people with places to live in the community and family support services for thousands more people waiting for help with residential needs. The close working relationship among families, advocates, the nonprofit provider community and New York State is a hallmark of this initiative and a major contributor to its success. The NYS-CARES concept continues with a 10-year commitment to develop additional services to meet family needs. Through a multi-year process, NYS-CARES II provides an additional 1,900 new out-of-home residential opportunities, 600 new opportunities for in-home services and 370 new opportunities for day services. It also provides additional funding for family support services beyond the State's initial commitment, to help individuals stay with their families as long as possible.
b. New York State Options For People Through Services (NYS OPTS) - The major new OMRDD program initiative is NYS OPTS. This is a systems change initiative based on the Organized Health Care Delivery System (OHCDS) model permitted under federal Medicaid regulations. The new initiative was designed by consumers, families, providers, self-advocates and other interested stakeholders to insure that the services are uniquely tailored to each individual.
The NYS OPTS initiative gives individuals with developmental disabilities and their families increased choice and individualization in available services. OMRDD continually evaluates its service system through customer satisfaction surveys. This method of evaluation will help insure that services funded through OPTS are of the highest quality and best suited to individuals' needs. It is anticipated that by 2007, more than 5,000 will be served under the OPTS initiative.
Use of health information technology (electronic health records, e-prescribing, electronic billing, etc)
A. New York State Department of Health
Medicaid Pharmacy Initiatives: Using the Medicaid Program Planning Mart, the claiming, collection, and disbursements to the federal and local governments of drug rebates collected from drug manufacturers was re-designed from an out-dated and unsupported mainframe system. This new drug rebate information system went into production effective April, 2004.
Introduced with the new system was the collection of rebates for drugs dispensed or administered by physicians and other non-pharmacy providers (J-Code procedures). These new rebates were retroactively collected back to January 2000. Beginning April, 2005, additional rebates began being collected from providers from whom no rebates were ever collected (340B providers). To date, this new drug rebate information system has saved New York over $133 million.
The Preferred Drug Program (PDP) encourages the use of drugs that are therapeutically appropriate and less expensive. The Pharmacy and Therapeutics Committee, which is comprised of physicians, pharmacists, nurse practitioners, and consumers, reviews selected categories of drugs using extensive, objective evidence based research outcomes from a variety of sources, including the Oregon Health Sciences University, to recommend which drugs are the most efficacious choices among the drugs in each therapeutic class. Certain agents are considered ?preferred? within a specific therapeutic class because they have unique clinical characteristics or because New York State will receive manufacturer rebates for certain therapeutically equivalent drugs that are considered equally effective, which lowers the cost. The Commissioner of Health makes the final determination of drugs that will be considered "preferred". Non-preferred drugs remain available through a prior authorization process.
The Department of Health is also instituting a Clinical Drug Review Program which is intended to assure appropriate drug therapy for Medicaid recipients by requiring prior authorization for drugs in which the Department has public health, or fraud and abuse concerns.
Through First Health Services Corporation, which has been contracted to assist the Department in implementing the PDP, New York has joined the National Medicaid Pooling Initiative. The Department has determined that pooling with other states by participation in the NMPI would realize greater cost savings than negotiating state-specific supplemental rebate agreements based on New York's purchasing power alone. The NMPI has pre-established supplemental rebates in place and is an expeditious way to begin implementation of a supplemental rebate agreement and to implement the Preferred Drug Program.
The Department is also working with First Health to implement a State Maximum Allowable Cost list for certain drugs for which no Federal Upper Limit has been established, which will reduce drug prices and result in cost-savings for the Medicaid Pharmacy program.
The Department has a fully operational mandatory generic drug program and currently requires prior authorization for Zyvox, Serostim, second generation prescription antihistamines, and prescription proton pump inhibitors which has resulted in significant cost savings to New York's Medicaid program.
B. New York State Office of Mental Health
Pharmacy Service and Clinical Knowledge Enhancement System:
The Pharmacy Service and Clinical Knowledge Enhancement System (PSYCKES) is an innovative health information technology product designed to support decision making and information needs for physicians and other clinicians, and improve the quality and safety of medication prescribing practices in the New York State public mental health system. PSYCKES' Web-based clinical decision support system uses state administrative databases to provide clinical data and information resources at the point of care, with drill-down and aggregation capabilities at the patient, physician, hospital, and system levels, and may serve as a model for other states, the federal government, and large payors. The PSYCKES project is designed to address several important opportunities.
First, there is broad consensus on evidence-based practices for mental health, including medications. All states are currently implementing one or more of the six evidence-based practices that the federal Substance Abuse and Mental Health Services Administration (SAMHSA) has recently published toolkits for, with 21 states implementing medication guidelines for schizophrenia. However, states need more information on effective methods for implementation. The NYSOMH PSYCKES initiative is providing critically important information regarding the effective implementation of evidence-based medication guidelines that may assist participating states.
Second, physicians' psychoactive medication prescribing practices are an area of urgent public health need. Numerous studies have documented that the practices of mental health professionals are often at variance with clinical practice guidelines and many patients receive suboptimal care leading to significant societal and financial costs; such variation is best documented in the area of pharmacological treatment. NYSOMH?s PSYCKES initiative is contributing toward standardizing medication practice patterns through its automated, guideline-driven performance measures that profile quality, safety, and conformance to evidence-based practices at the hospital and physician levels.
Third, an increasing number of studies have examined the feasibility of using mental health administrative and pharmacy databases, which are universal among payers, to assess conformance with evidence-based practices. These studies document conformance rates in large populations and represent a methodological advance in quality improvement. Taken together, these studies suggest that administrative and pharmacy databases are inexpensive and reliable sources for determining some measures of guideline adherence, including dose and duration of medication trials, patient adherence to medication regimen, and outpatient follow-up after hospitalization.
The NYSOMH PSYCKES initiative is utilizing state administrative databases to provide clinical data and information resources at the point of care. PSYCKES capitalizes on the already existing data NYSOMH maintains for billing, pharmacy, budgeting, and clinical information. These databases have the potential to support a broad range of clinical management needs at the state, facility, provider, and individual client level, but integrating and making them broadly available for decision support had not been done prior to PSYCKES.
Description of PSYCKES - PSYCKES' novel Web-based clinical decision support system utilizes advances in health information technologies to support decision making and information needs for physicians and other clinicians and to improve the quality and safety of medication prescribing practices in the NYS public mental health system. Through its unique integration of patient data, clinical practice guidelines and information resources, PSYCKES addresses the information dissemination change driver identified in this application.
PSYCKES contains two types of information: 1) all available patient treatment history data for the past 15 years for all patients currently served in New York's 26 adult, child, and forensic state psychiatric hospitals, and 2) context-based links to information resources including RxList, PubMed, and clinical practice guidelines. PSYCKES pulls data from many state administrative databases to coalesce 15 years of history of prescribing, admissions, and diagnoses. All data processing and reports are written in SAS (SAS Institute, Inc., Cary, NC) and the timelines graphs are written in Ploticus (ploticus.sourceforge.net). For each patient and hospital, PSYCKES includes over 1,000 database queries, and generates over 140 customized links. PSYCKES is a secure, HIPAA compliant application: users need to obtain a security clearance with three levels of approval and use a password to log on. State level users have access to all data in the system. Hospital level users have access to performance data at the state and hospital level, system wide, and can view historical data from any hospital for their current patients, but cannot view data for patients at other hospitals.
PSYCKES organizes clinical data into two linked categories: 1) clinical reports, designed to support clinical decision making, and 2) management reports, designed to support quality improvement (Table 1). Clinical reports have been developed with feedback from users to ensure that reports do not contain more or less information than physicians need to quickly review a patient?s history to make a clinical judgment. PSYCKES includes six sets of patient-detail clinical reports that offer access to 15 years of psychotropic data.
All PSYCKES reports are hyperlinked to support rapid navigation from state overviews, down to individual patient orders. Some of the indicators summarize current data (e.g., percent of patients on higher than recommended doses). Other measures take advantage of the historical database to make more complex judgments (e.g., identifying patients who are eligible for clozapine, a medication of choice for treatment resistant schizophrenia, involves review of all data since the medication's introduction). When appropriate each report presents performance on the indicator as measured, (e.g., number and percent of patients receiving lower, within, or higher than recommended range), as well as a break out on degree of deviation (e.g., 1.5X, 2X, 3X, 4X higher than recommended range).
Summary - PSYCKES is a new and creative method for using administrative and pharmacy data to support clinical decision-making at the level of the individual patient. While all states share some clinically relevant patient-specific state database generated information with treating physicians in a limited paper-based fashion, to the best of our knowledge, no other state has developed and offered an integrated, guideline-driven, web-based clinical and fiscal decision support system for psychiatry. The key distinctions between PSYCKES and other existing medication management systems are:
1) Aggregation of 15 years of history into clinically usable form.
2) Focus on providing the details of those data to front-line clinicians, and through them, patients and families.
3) Ability to drill-down into data at the levels of state, hospital, clinician, ward, patient, and finally raw orders, allowing all users maximum flexibility to evaluate the data for themselves.
Learn more about PSYCKES
Expanding coverage through private sector initiatives
A. Partnership for Long-Term Care Program
New York is one of the original four states (NY, CT, IN, and CA) that offer a Partnership for Long-Term Care program (Partnership program). The Partnership program links private long-term care insurance with Medicaid, as backend insurance, and provides lifetime coverage for long-term care. The New York State Partnership program offers Medicaid asset protection while fostering personal responsibility by encouraging individuals to plan financially for future long term care needs. New Yorkers who have purchased Partnership policies and exhausted their coverage can apply for Medicaid Extended Coverage and have all or part of their assets protected, i.e., excluded from spend down requirements. (Medicaid income rules are applied in determining Medicaid eligibility.) At the same time, the Partnership program substitutes private funds for Medicaid funds for the payment of long term care services. The Partnership program provides New Yorkers with a reasonable and affordable option at a time when the Federal and State governments are considering Medicaid eligibility reform.
B. Partnership: Grantmakers Alliance of Northeastern New York New York State Office for the Aging - Leveraging Influence and Resources to Create Vital Communities
Traditionally, social programs, and the financial resources that fund them, are targeted or restricted to discrete segments of the population. Funding is tied to distinct, disconnected networks. Little or no collaboration or coordination occurs among networks or sectors in planning for community needs and in designing programs. Too often, addressing the well-being of individual age groups or population segments is not integrated within the context of addressing the overall well-being of the community.
Against this background, the New York State Office for the Aging and six foundation members of the Grantmakers Alliance of Northeastern New York have joined forces to model an innovative inclusive, global planning and programming process, which is meant to assist communities in the Capital District of New York State to prepare for the impact of anticipated changes in their demographic profiles.
The partners will jointly lead ventures that will raise awareness of New York's dramatically changing demographic profile, help communities understand the future implications of these changes, and take steps, in innovative ways, to prepare themselves for these implications.
Transparent and publicly-accessible measurements of patient outcomes and/or quality improvements
A. New York State Department of Health
1. Quality Assurance Reporting Requirements:
New York State collects and analyzes information from Medicaid managed care plans to track performance and consumer satisfaction information. Known as "QARR" -- Quality Assurance Reporting Requirements, the program uses measures largely adopted from the National Committee for Quality Assurance - Health Plan Employer Data and Information Set. New York State-specific measures are included to track public health issues of particular importance in New York State.
The report on 2005 QARR data showed that the quality of care provided through Medicaid managed care continues to rate among the best in the nation. New York exceeded averages in 21 comparable national measures of quality showing large differences in women's, perinatal and diabetes care, outpatient visits for depression, and follow-up care to hospitalization for mental illness.
A report by the National Committee for Quality Assurance and U.S. News and World Report (The State of Health Care Quality 2005) ranked New York State as having five of the U.S. top 20 Medicaid managed care plans.
More information on QARR and the 2005 report are available online at: http://www.nyhealth.gov/health_care/managed_care/reports/eqarr/2005/index.htm http://www.nyhealth.gov/health_care/managed_care/reports/eqarr/2005/about.htm www.nyhealth.gov/press/releases/2005/2005-10-12_eqarr_release.htm
2. Pay for Performance Demonstrations:
In spring 2005, Governor Pataki signed into law a new Pay for Performance initiative intended to foster collaborations between Medicaid, commercial payers, employers and providers. The new law was designed to promote patient safety, quality of care and cost effectiveness by rewarding hospitals, physicians and clinics that provide high quality care. The legislation directed the Commissioner of Health to establish a Pay for Performance (P4P) Workgroup comprised of healthcare provider associations, health care plan associations, hospital representatives, consumers, labor and self-insured employers. The Workgroup's mission was to seek consensus on clinical measures and measurement criteria necessary and appropriate to achieve improvement in quality performance by providers in delivering health care services. These clinical measures are to be used in 5 regional demonstration projects involving multiple payers, including Medicaid, and designed to provide financial incentives to hospitals, physicians and clinics to improve performance. An RFP was issued in May 2006 with awards expected to be made by fall. The State is providing $10 million dollars to fund the demonstrations.
3. Quality Incentives:
To further strengthen its commitment to quality, the State has implemented a "pay for performance" program that provides financial rewards to Medicaid managed care plans that achieve high quality and member satisfaction ratings. Health plans can earn incentive payments of up to 3% of premium for superior performance. About one-half of the health plans that participate in the Medicaid managed care program have earned incentive payments ranging from .75% to 3.0% of premium. Plans use these incentives to invest in quality improvement and to reward providers. The total value of the incentive payments was approximately $45 million in 2005 with 18 plans receiving some level of incentive payment. The Commonwealth Fund has awarded a grant to the Urban Institute to conduct and evaluation of the effectiveness of the quality incentive program.
4. Disease Management:
The Department of Health recently announced the creation of six regional demonstration projects totaling $6.5 million in grant awards to help address the complex health care needs of Medicaid recipients with chronic illness or at-risk for disease. The demonstrations will promote the development and implementation of innovative approaches to providing disease and care management services in the areas of heart disease, renal kidney failure, and mental illness, among other types of chronic illness to New Yorkers enrolled in Medicaid.
One of the primary goals of the projects is to promote the doctor, patient relationship in delivering quality health care so that patients have a greater understanding of their treatment options and become more involved in making health care decisions. Each program will be evaluated by the Department to determine the efficiency and effectiveness of providing health care to patients under these programs. The services are available to those enrolled in Medicaid under fee-for-service. More information click here
5. General Quality Improvement:
The Medicaid program, in conjunction with its utilization review and quality improvement organization contractor, the Island Peer Review Organization (IPRO) has been conducting ongoing quality improvement projects (QIP) for 10+ years. Historically, IPRO concentrated QIP efforts in the inpatient arena, coupled with utilization review contract deliverables. In 2000 the QIP initiatives were retooled to address chronic care conditions in the ambulatory setting; with a focus on asthma and diabetes. These initiatives are modeled after the nationally acclaimed, evidenced-based 'Chronic Care Model' (Dr. Ed Wagner, the MacColl Institute for Healthcare Innovation, Center for Health Studies, Group Health Cooperative). A major goal of these QIPs is to facilitate productive interactions between an informed activated patient and their prepared, proactive health care team. Currently, there are 25 Article 28 clinics participating in the Asthma QIP and 19 diabetes clinics. Key programmatic components include: real-time chart audit reviews including provider feedback (Peer Report Cards), academic detailing (translating knowledge to practice), clinical decision support tools (i.e., chart prompts), links to community resources, communication skills and patient self-management training, etc. To date, these initiatives have been successful at achieving 'key' clinical performance measures. Both of these initiatives have been recognized on a national level (CDC- asthma, EPA- Asthma Health Outcomes Project, and ADA- diabetes). IPRO is currently conducting further analysis of these initiatives with a focus on return-on-investment.
In addition to these QIPs, the state Medicaid program is actively involved with many public health task forces including: NYS Diabetes Prevention and Control Program, NYS Asthma Plan, Arthritis Task Force, Healthy Heart Program, NYS Smoker's Quit Line, etc. NYS Medicaid partners with various public health programs in sharing of resources and giving Medicaid recipients the benefit of sound public health principles. New York also shares Medicaid aggregate population-based data in an effort to assist public health in assessing the effectiveness of their various interventions. These efforts support representation and alignment of health care needs to better serve recipients known to have chronic disease.
The New York State 'Medicaid Update' monthly publication is used to disseminate information to providers on evidenced-based treatment guidelines, and patient educational tools to share with Medicaid recipients to promote improved self-management of their chronic disease(s).
B. New York State Office of Mental Health
Historically, the OMH has collected and reported results of performance through a variety of formats such as evaluation reports, Statewide Comprehensive Plans, progress reports, professional publications, technical reports and others. In addition, OMH is now leveraging its data warehouse and related resources to implement a balanced scorecard that is accessible to the public via the Internet. The balanced scorecard approach was adopted to achieve three fundamental goals:
- To combine existing data sources into a secure, integrated database and balanced scorecard platform for performance analysis, reporting and monitoring.
- To disseminate the performance data online and through other mechanisms such as formal written reports to educate stakeholders and guide advocacy and awareness efforts.
- To establish performance benchmarks to spur quality improvements, inform management decision making and policy planning, provide a basis for evaluating progress and making necessary adjustments to achieve performance targets, and develop recommendations for future mental health care initiatives.
Concurrent with implementation of the Balanced Scorecard, information has been made available on the OMH Website on New York State?s Assisted Outpatient Treatment (AOT) program. The June 2005 amendment to the legislative extension of Kendra's Law, which established the state's AOT program, included a provision to make performance information available beginning March 1, 2006. Using the same technology that underlies the Balanced Scorecard, a set of indicators specific to the AOT program has been made available to the public.
Information presented on the AOT program includes:
- Characteristics and demographics of individuals served by AOT, including the incidence and duration of homelessness, hospitalization and incarceration of individuals before and during AOT.
- Outcomes of judicial proceedings, including the number of AOT petitions granted by the court.
- Number of service enhancements or voluntary agreements not ordered by the court.
- Treatment referral outcomes, including the time frames for service delivery.
- Number of removals for examination pursuant to subdivision (n) of Section 9.60 of the Mental Hygiene Law and the number of persons who are hospitalized beyond the period of examination.
- Reasons for closed cases.
- Data reported pursuant to subdivision (b) of Section 9.47 of the Mental Hygiene Law.
- Other data related to the AOT program deemed appropriate by the OMH Commissioner.
C. New York State Office of Alcoholism and Substance Abuse Services
The goal of OASAS' Managed Addiction Treatment Services (MATS) is to assure effective and appropriate access to needed treatment services and positive treatment outcomes for recipients of chemical dependence services. Concomitantly, MATs drives savings in the State's Medicaid program through the reduction of unnecessary or excessive utilization of Medicaid services. In February 2005, OASAS solicited proposals from local mental hygiene agencies for the operation of MATS programs, building on the existing Managed Addiction Treatment Services County Demonstration model. By providing Federal and State funding to local mental hygiene agencies/Local Government Units (LGUs), OASAS' goal is to expand and enhance MATS programs throughout New York State.
The new MATS program will improve the delivery of health care and other related services to Medicaid recipients requiring treatment for chemical dependency, by targeting the provision of case management services to voluntarily participating high cost Medicaid-eligible recipients of chemical dependence services. MATS programs will be carried out at the county/NYC level through a partnership between the local mental hygiene agency and the local department of social services.
MATS program services will include, but not necessarily be limited to: Assessment; Service Planning; Resource Identification; Creating Linkages; System Coordination; Advocacy; Service Monitoring; Utilization Management; Brokering; Crisis Intervention; and Creative Problem Solving. Local MATS programs will be financed through a combination of Federal Medicaid Administration funding, State Aid and local government matching funds.
Efforts to combat fraud and abuse
New York State has a variety of best practices and initiatives designed to combat fraud, waste and abuse in the New York State Medicaid system, including but not limited to the following:
A. Establishment of the New York State Office of the Medicaid Inspector General (OMIG)
New York State recognizes the critical importance of program integrity activities. On February 2, 2006, Governor Pataki issued Executive Order No. 140.1 which established the NYS OMIG. The OMIG is an independent entity within the New York State DOH and serves as the centralized entity to combat Medicaid fraud, waste and abuse activities in New York. Formerly, New York's Medicaid fraud, waste and abuse control activities were conducted by the DOH's Office of Medicaid Management and various State regulatory agencies, which, while having been successful at recouping, withholding or avoiding $12.8 billion of overpayments since 1999, suffered from fragmentation among the various state agencies and offices charged with Medicaid fraud-fighting responsibilities. The system needed more focus on specific auditing and fraud prevention goals and needed greater coordination and communication among the State agencies engaging in fraud, waste and control activities. Accordingly, the OMIG that was established is responsible for all Medicaid fraud, waste, and abuse control functions, ensuring a more focused and coordinated approach.
Specific programs
1. Post and Clear:
New York is on the cutting edge with a benchmark program called "Post and Clear." Providers who are required to participate must ?post? their prescription orders through an electronic clearinghouse maintained by the OMIG. Pharmacies filling those orders then "clear" them upon dispensing. This system helps to ensure that only the specific services and supplies requested by the posting provider are furnished. It aids in the elimination of fraudulent practices such as forged prescriptions and duplication of services.
2. Provider Data Cleansing Project:
New York has recently contracted with the largest database company in the United States to obtain information about Medicaid providers that is not currently available through the NYS Medicaid enrollment process. The project will assist the OMIG in identifying national sanctions, licensure actions, corporate dissolutions, criminal prosecution and other factors that would identify providers whose participation in the NYS Medicaid program is questionable and requires review.
3. Forge Proof Prescriptions:
New York State has implemented a program designed to eliminate the availability of photocopies and computer printed prescription pads that are used by unscrupulous recipients to create their own prescription for marketable street drugs. The program also establishes a mechanism to invalidate prescriptions that are stolen. Each prescription contains a preprinted unique serial number that is associated with registered prescribers. These serial numbers allow prescribers to report the theft of a prescription form to the NYS DOH, Bureau of Narcotics Enforcement. This information is used by the OMIG for denial of claims, fraud targeting and inclusion of providers in the Post and Clear program. Building on this initiative, NYS is planning an e-prescribing environment to allow prescribers a secure alternative to paper prescriptions. This effort will enhance the State's ability to control fraud, waste and abuse in Medicaid prescribing practices.
4. Undercover Operatives:
New York has had much success with the use of undercover operatives posing as Medicaid recipients that obtain services from enrolled providers such as doctors, pharmacies and clinics. These undercover investigations have identified inflated claims, services not provided and illegal relationships between various provider entities.
New York has been in the vanguard nationally in instituting a prescription drug monitoring program, including moving to electronic prescriptions for controlled substances as a means of ensuring that such are used by the individual for whom prescribed and averting the ability to fill one prescription multiple times. At the Federal level, oversight of this effort is shifting from the Department of Justice to the Department of Health and Human Services. Under legislation enacted last year, future Federal funding for drug abuse treatment would have been tied to states having a Prescription Monitoring Program (PMP) that was funded by DHHS. The New York State Office of Alcoholism and Substance Abuse Services, working through the National Association of State Alcohol and Drug Abuse Directors (NASADAD) has assisted in crafting language that permits DHHS to deem a precedent PMP program as equivalent to that funded by DHHS; the result is that New York will be able to apply for future drug treatment grants for services - many of which are funded by Medicaid - without having to reconstitute the PMP.
5. Credential Verification Review:
The OMIG's Bureau of Investigation conducts unannounced visits to Medicaid provider offices and facilities to verify practitioner credentials as well as the adequacy of office and facility environment. This initiative has been successful in identifying and rooting out suspect providers enrolled in the program.
6. Provider Targeting/Data Mining:
New York State has an array of data mining and analysis tools to provide easy access to claims and reference data stored in our claims data warehouse. These tools provide the OMIG staff the ability to conduct sophisticated analysis of query results. Available tools include but are not limited to algorithm based modeling, mapping capabilities of Geo-coded data, and statistical analysis of large data sets.
B. New York State Office of Alcoholism and Substance Abuse Services (OASAS)
1. Fraud and Abuse:
As part of the September, 2005 OASAS reorganization, the Bureau of Enforcement under the Division of Legal Affairs is the central "point of contact" for those compliance and quality of care concerns that rise to the level of potential waste, fraud, and abuse. The Bureau also serves as a central coordinating point for complaints against credentialed counselors/prevention practitioners, operates the patient advocacy unit, conducts priority program investigations and targeted compliance reviews, and maintains a follow-up system to confirm provider compliance with approved corrective action plans. OASAS has recently taken enforcement action against two certified proprietary substance abuse treatment providers on Long Island. One of these providers, was fined $6.9 million for infractions of patient care and patterns of repeated regulatory violations and their operating certificates were revoked. The other provider was fined $1.5 million for illegal operations and improper Medicaid billing practices. In both instances, OASAS took the necessary action to ensure that affected clients were transitioned into other treatment programs that best suited their individual treatment needs.
2. Targeted Provider Utilization Review:
OASAS has also proposed to amend its chemical dependence (CD) outpatient treatment services regulation (Part 822) in order to: strengthen provider utilization review requirements; reduce excessive and unnecessary services; and control the ratio of group to individual counseling sessions. The proposed regulatory standards will advance OASAS' commitment to promote appropriate and needed services to addicted individuals, while at the same time creating savings in Medicaid expenditures. It is anticipated that significant Medicaid savings and cost avoidance will be achieved when these standards are fully implemented.
a. Utilization Review Standards - Section 822.6: In order to assure that the duration, frequency, and intensity of services to addicted individuals enrolled in a CD outpatient service are limited to therapeutically appropriate levels, OASAS is proposing more prescriptive utilization review requirements for providers. Specifically, under the new regulatory requirements, providers must complete monthly utilization reviews of:
- A random sample of 50% of all cases active between 270 and 365 days;
- 100% of all cases active for over 365 days;
- 100% of all clinic cases active for over 120 days which are receiving three or more service visits per week; and
- 100% of all rehab cases active for over 180 days which are receiving three or more service visits per week.
b. Excessive Provision of Service Standards - Section 822.10:
In developing excessive provision of service standards, OASAS graphically analyzed each provider's Medicaid claims per patient for the period July 1, 2003 through June 30, 2004 and determined distribution breakpoints (see attached) at which provider specific clinic and rehabilitation billings per patient rose markedly above normative levels. Based on this analysis, OASAS proposes the adoption of standards to control excessive provision of service, consisting of Decertification and Red Flag Thresholds, as follows:
| 9 Month Standards | 12 Month Standards | |||||
| Program | Number of Providers |
Historical Average Number of Visits Per Patient (12 Months) |
Red-Flag Threshold | Decert Threshold | Red-Flag Threshold | Decert Threshold |
| OP Clinic | 313 | 34.4 | 45 | 60 | 50 | 65 |
| OP Rehab | 58 | 45.9 | 50 | 65 | 55 | 70 |
For providers determined to have an average number of visits per patient above a Decertification Threshold, OASAS proposes to initiate revocation action against the provider's operating certificate. For providers determined to have an average number of visits per patient above a Red-Flag Threshold, but below the applicable Decertification Threshold, OASAS will initiate aggressive follow-up with the provider, focusing on intensive monitoring of the provider's compliance with OASAS' new UR standards (Section 822.6) and any corrective action efforts to address inappropriate patient lengths of stay and excessive service intensity.
c. Group to Individual Counseling Services Standard - Section 822.2
To assure that patients do not receive an excessive level of group versus individual counseling services during their treatment in a CD outpatient service, providers will be required to provide at least one individual counseling session to each patient, by the patient's primary counselor, for every nine group counseling sessions provided (i.e., the ratio of group to individual counseling sessions may not exceed 9:1).
What changes would you make to the federal Title XIX so that you couldprovide better services to individuals and families on Medicaid in your state?
A. New York State Department of Health Medicaid Program
1. Simplify Rules and Categories:
The Medicaid Program has evolved over the years and has become a very complex program to understand and administer. In order to assure access to needed benefits and to ensure program integrity, a plan to simplify eligibility rules and categories of assistance is needed. In a state such as New York, there exist no less than 18 categories of assistance and as many methods under which eligibility must be evaluated for individuals applying for assistance. Simplification of such processes will no doubt reduce confusion on the part of needy persons applying for benefits and reduce administrative errors caused by the complexity of the program.
2. School Supportive Health Services:
For more than a decade, schools across New York State have been providing essential health-related services to disabled children under the School Supportive Health Services Program. In this especially complex area, schools are required to comply with the Individuals with Disabilities Education Act ("IDEA"), which focuses on how the services assist the child in meeting long term goals, while also complying with the technical record-keeping and billing requirements of Medicaid, which focuses on how the services are provided.
The absence of federal guidance in this highly-complex area has been criticized in a series of reports produced by the federal General Accounting Office (GAO), which has complained of "inconsistent guidance." The President noted in his 2003 budget proposal that "the federal government has never articulated clear guidance," for the program, and said that "[i]n 2002, the Administration will release guides that will address all aspects of school-based Medicaid billing."
To date, however, despite the President's statement, no clear guidance has been provided. At the same time, the federal government has taken deferrals and recommended disallowances against local school districts for not complying with the admittedly unclear guidance.
In these circumstances, the federal government should consider revising its approach, and focus on developing clear guidelines that will allow school districts to obtain Medicaid reimbursement for necessary eligible services. It should avoid taking deferrals and disallowances that would punish school districts (and their children) that have provided necessary medical services, but may not have complied fully with the admittedly unclear guidance.
B. New York State Office of Mental Health
The Medicaid Rehabilitation option should be fully available to finance medically necessary rehabilitation oriented behavioral health services. States need guidance on what services will be covered and what the audit criteria will be. Also, for individuals with serious mental illness there is a disincentive to work if earning a wage means losing Medicaid coverage. Title 19 should be reviewed to allow medical coverage to continue for individuals with mental illness who have been successfully employed.
C. New York State Office of Alcoholism and Substance Abuse Services
1. IMD Exclusion:
Medicaid is not available, under the Federal Social Security Act, to any individual between the ages of 21 and 64 who lives in "a hospital, nursing facility or other institution of more than sixteen beds, that is primarily engaged in providing diagnosis, treatment or care... [for] mental diseases, including medical attention, nursing care, and related service" (the institution for mental disease exclusion or "IMD exclusion"). As mental disease is further defined under this legislation to include substance abuse, any person who resides in a treatment facility with more than 16 beds is ineligible for Medicaid payments for any health care service, whether the health care service is provided at the treatment facility or off-site (e.g., a clinic).
The IMD exclusion presents a barrier to sound clinical determinations, as referral to a residential treatment program imposes a significant additional cost on the State through the loss of Medicaid. In addition, it undermines public policy goals including those articulated by the Federal Substance Abuse and Mental Health Services Administration (SAMHSA), as numerous national studies have documented that substance abuse treatment is effective, generates substantial savings at all levels and fosters individuals? ability to be self-sufficient.
In New York, the IMD exclusion is additionally problematic as residential treatment facilities rely on off-site healthcare providers for other treatment needs of their patients (e.g., primary healthcare). For many patients, the most appropriate level of care for their substance use disorder is residential treatment (inpatient rehabilitation, intensive residential treatment and community residential treatment programs). An unintended consequence of the patient's acceptance of this level of care is that they become ineligible for Medicaid support for other necessary healthcare services. This places an undue financial burden on the residential treatment facility or may lead to a premature discharge so that the patient's other healthcare needs may be addressed.
If the patient is pregnant, this exclusion is particularly unsound as their acceptance of residential treatment precludes Medicaid reimbursement for all other healthcare, including, for example, obstetrical services which are key to ensuring the best outcome for the health of the baby; conversely treatment for her substance use disorder is particularly urgent, as continued use of alcohol and/or drugs is likely to result in physical disabilities and problems with learning, memory, attention, problem solving, and social/behavioral problems for their children.
2. Medicaid for Inpatient Treatment in Free-Standing Facilities:
While States may include services provided in free-standing clinics under their State's plan for Medicaid, there is no such provision for inpatient treatment provided in free-standing facilities. In New York, inpatient rehabilitation for chemical dependence is provided at hospitals and in free-standing facilities, including the 13 State operated Addiction Treatment Centers (ATC); the cost per day is substantially higher in the hospital setting. Under a demonstration grant in the early 1990s, New York demonstrated the cost effectiveness and efficacy of Federal reimbursement for this level of care for those with substance abuse disorders (i.e., treatment in non-hospital settings, which are far less costly, while assuring medical oversight and supervision). DHHS should allow State plans to include free-standing inpatient treatment to maximize opportunities for effective treatment, in sufficient intensity to assist the patient toward recovery, while containing costs.
What are your future plans?
A. New York State Department of Health
1. Long-Term Care Insurance Education and Awareness Campaign:
In Spring 2006, New York will launch a comprehensive statewide Long-Term Care Insurance Education and Awareness campaign highlighting the need for New Yorkers to plan financially for their future long term care. In addition to its web site: www.planaheadny.com and a new long-term care insurance helpline at 1-886-950-PLAN, the campaign will rely on television, radio, and print advertisements, direct mailings to the public, and county Long-Term Care Insurance Resource Centers.
2. Long Term Care Restructuring Initiative:
In January 2004, the Governor's Workgroup on Health Care Reform issued a report making sweeping recommendations for improvements in the State's long term health care system.
Working cooperatively with the New York State Office for the Aging (NYSOFA), the New York State Department of Health (DOH) was charged to realize this major restructuring effort. The goal is to rebalance all the elements of the State?s long-term care system, including the creation of a new comprehensive Long Term Care (LTC) Medicaid Waiver intended to develop more home and community based services and to change the design, delivery and eligibility requirements of Medicaid and other State funded programs. The Department is preparing to release a Request for Information (RFI), in Spring of 2006, to gather more targeted input on the overarching LTC service design and to pursue a new comprehensive 1115 waiver for persons of all ages that will offer comparable services to those currently provided through several individual Medicaid waiver programs.
3. Nursing Home Transition and Diversion (NHTD) Medicaid Waiver:
Legislation passed in the fall of 2004 directed the Department of Health (DOH) to apply for a Nursing Home Transition and Diversion (NHTD) Medicaid Waiver. An application for the NHTD waiver was submitted to the Centers for Medicare and Medicaid Services (CMS) on December 12, 2005.
The NHTD waiver will provide community-based alternatives to individuals with disabilities, who are at least eighteen years of age, in receipt of Medicaid and assessed to be at the nursing home level of care. The NHTD waiver will allow individuals to avoid or transition from unwanted nursing home placement. Administratively, this waiver will be structured after New York's TBI waiver.
In its application to CMS, DOH requested the opportunity to serve at least five thousand (5,000) individuals within the first three years of the waiver. Such individuals will be eligible to receive a variety of comprehensive community-based services and supports.
Our application to CMS requests approval for the following services: Service Coordination; Respite; Independent Living Skills Training; Structured Day Program; Positive Behavioral Interventions and Supports; Community Integration Counseling; Home and Community Support Services; Community Transitional Services; Environmental Modifications Services; Assistive Technology; Congregate and Home Delivered Meals; Respiratory Therapy; Moving Assistance; Home Visits by Medical Personnel; Nutritional Counseling/Educational Services; and Nursing Assessment.
It is anticipated that the NHTD waiver will be approved in the summer of 2006.
B. Office of Alcoholism and Substance Abuse Services
Recent research has identified Evidence Based Practices (EBPs) to better address the chemical dependence treatment needs of adolescents; and OASAS is now seeking to develop a service delivery system to more effectively serve adolescents (up to the age of 21). Over the last few years, OASAS has identified chemical dependence services to adolescents as a high priority and has worked, in collaboration with residential treatment service providers, to develop a new program model for residential rehabilitation services for youth. This new model incorporates the clinical benefits and strengths inherent in both of the existing residential program models to not only assure more clinically effective services, but also to conform to applicable Federal Medicaid reimbursement criteria (under the Inpatient Psychiatric Services for Individuals under 21 rubric), allowing for a more stable and recurring revenue stream for these important services.
OASAS, in collaboration with the New York State Department of Health (DOH), is currently working toward implementing this new residential rehabilitation services model, to be phased-in over a three year period, beginning in the summer/fall of 2006. Major activities completed to date include: proposed operating regulations (Part 817) for the new services; an approved fee model for the establishment of Medicaid fees for the new service; proposed amendments to OASAS? Medicaid regulations (Part 841), in support of the new fees; and submission of the Medicaid State Plan Amendment for the new service and fees.
Major remaining tasks include: adoption of the new service regulations; Federal approval of the Medicaid State Plan Amendment; and, conversion to operate under the new OASAS regulations for those providers selected for the first phase.
