"Meeting Challenges: Trying to Stay One Step Ahead"

1. "Meeting Challenges: Trying to Stay One Step Ahead" Steve Hanson Associate Commissioner Treatment & Practice Innovation

2. “ The times, they are a-changing” - Bob Dylan

3. What’s Changing in Treatment? Almost Everything! • Substances being used • Models for Treatment • Managing Care • Insurance Coverage • Payment Mechanisms • Performance Measures

4. Substances Being Used • Alcohol, Cocaine, Marijuana, • Opiates – Heroin & Prescription • Designer Drugs

5. 2011 National Survey on Drug Use and Health (NSDUH),

6. 2011 National Survey on Drug Use and Health (NSDUH),

7. 2011 National Survey on Drug Use and Health (NSDUH),

8. OASAS - 2011 Treatment System Fast Facts

9. 2011 National Survey on Drug Use and Health (NSDUH),

10. 2011 National Survey on Drug Use and Health (NSDUH),

11. 2011 National Survey on Drug Use and Health (NSDUH),

12. 2011 National Survey on Drug Use and Health (NSDUH),

13. 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

14. 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

15. Lab-Based Drug Testing (2010):

16. Lab Testing 2012

17. Analog Prevalence 2010

18. Analog Prevalence - 2012

19. Managed Care

20. 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.

21. 2010 Detox Top 1000 Users

22. One Person in 2010 73 Detox Admissions 15 Detox Providers 291 Detox Days Over $300,000 Cost

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

24. 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

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

26. 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.

27. 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.

28. Providers in the Middle Inpatient Rehab Intensive Residential Outpatient Rehab

29. 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

31. 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

32. Improving Performance • Governor/Commissioner’s Goals of Improving outcomes for patients • Federal goals of performance improvement for Block Grant • Identifying good outcome measures

33. 26.9% 46.3% 61.3% 54.7% Adverse Discharges

34. Pay for Performance • Current “Net Deficit” funding mechanism does not address program outcomes. • System to “pay for performance” under development

35. 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)

36. OASAS Goals • Review Treatment models to ensure: • Best Outcomes • Appropriate Care • Reasonable Length of Stay • Program Accountability