Trying to Stay One Step Ahead

"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),
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.
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
Top 100 Next 900
$11 million
$39 million
$159 million
One Person in 2010
73 Detox Admissions
15 Detox Providers
291 Detox Days
Over $300,000 Cost
It is Time to Change
Oh, Darn
Was that
BHO Phase II
• All Medicaid Covered Lives have managed behavioral
• 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
It’s Complicated
•NYC and ROS
•CMS requirements
•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
• 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.
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
• 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
Adverse Discharges
Pay for Performance
• Current “Net Deficit” funding mechanism
does not address program outcomes.
• System to “pay for performance” under
Treatment Models
• NY has utilized treatment models that are
somewhat different than the rest of the
• US Median IR LOS for Treatment
Complete – 90 days
• NY Median IR LOS for Treatment
Complete – 189 days (221 with Transfers)
• Review Treatment models to ensure:
– Best Outcomes
– Appropriate Care
– Reasonable Length of Stay
– Program Accountability

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