"Meeting Challenges: Trying to Stay One Step Ahead" Steve Hanson Associate 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),

OASAS Treatment System Fast Facts

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.

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

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 21

One Person in Detox Admissions 291 Detox Days 15 Detox Providers Over $300,000 Cost

It is Time to Change Oh, Darn Was that Today?

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 24

It’s Complicated Issues: 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 Outpatient Rehab Intensive Residential

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