In 2011, New York Governor Andrew Cuomo established the Medicaid Redesign Team (MRT). Composed of stakeholders and experts from throughout the state, the team was tasked with working collaboratively to review and redesign New York's Medicaid system. The Action Plan they developed set forth a roadmap for a complete system overhaul, including, among other reforms, "ending the state's Medicaid FFS system and replacing it with a comprehensive, high-quality and integrated care management system." To implement the full action plan, New York submitted an amendment to the state's existing Medicaid 1115 waiver demonstration. The finalized terms and conditions of the amendment were announced in 2014. The MRT was named a finalist for the 2015 Innovations in American Government Awards by Harvard University's Kennedy School of Government for its work, and especially for its "intensive stakeholder engagement process" in designing a health care delivery system with equal emphasis on cost and quality.
This system redesign has a far-reaching impact on New York's behavioral health system. Whereas the state's Medicaid system had previously carved out mental health and SUD treatment services, full integration of health care within a managed care environment calls for a single care management organization to take on the responsibility of managing its members' complete needs--their physical and behavioral health service needs, both acute and long-term. The action plan further recommended that these reforms include safeguards to prevent "the 'medical model' of care from displacing community-based behavioral health service delivery." The reforms were rolled out starting in October 2015; MRT expects the redesign approximately 5 years to be fully implemented.
Additionally, New York is one of eight demonstration states for the federal Excellence in Mental Health and Addiction Treatment Expansion Act (Excellence Act) to improve access to community mental health and addiction treatment services. The Excellence Act defines and established criteria for Certified Community Behavioral Health Clinics (CCBHCs) that provide a set of required services, with an emphasis on crisis care, evidence-based practices, integration with physical health care, and care coordination. As part of the Excellence Act demonstration, 13 CCBHCs were established around New York State and began serving their communities in July 2017. This initiative dovetails with the MRT Action Plan's emphasis on avoiding hospitalization for behavioral health services that can be provided in a community setting. The chief counsel for the New York Office of Alcoholism and Substance Abuse Services (OASAS) expressed optimism about the contribution of the CCBHCs toward the state's goal of putting in place a comprehensive, integrated, and community-based behavioral health service delivery model; at the same time, he also pointed out that "this is still very much a work in progress."
These recent and currently unfolding reforms at the state level necessitate substantial practice transformation at the provider level. We next turn to New York's efforts to support the behavioral health workforce during this challenging transition.
Available Substance Use Disorder Workforce Supports
Training and Technical Assistance Resources
In planning and implementing the system overhaul, state officials were mindful of lessons learned from states that preceded New York in implementing similar structural reforms; in particular, they focused on the challenges that providers would face in adapting to the new system. In 2014, before the new system was rolled out, OASAS and the Office of Mental Health (OMH) contracted with Community Technical Assistance Center of New York (CTAC) and Managed Care Technical Assistance Center of New York (MCTAC) to work with behavioral health providers across the state in preparation for the transition. The co-director of CTAC/MCTAC summarized the role of their organization as "a bridge between system transformation and clinical or practice transformation." He added that in those states that transitioned their behavioral health systems from FFS to managed care without a similar "bridge," providers had difficulty adapting to the new system and some even went out of business, an eventuality that the New York redesign tried to avoid. In New York's Medicaid system, this transition was accompanied by a shift from a "carve-out" to a "carve-in" approach to behavioral health services and the introduction of a value-based payment environment, making the transition even more difficult for providers and adding urgency to the need for advance and ongoing training and technical assistance.
The partnership between OASAS and CTAC/MCTAC in supporting providers to weather the system overhaul has been successful in helping ease this transition. According to the CTAC/MCTAC co-director, one important factor that has helped is the "in-between" position of his organization. Given that CTAC/MCTAC is a non-government agency, providers feel encouraged to engage with them in a less guarded manner. Consequently, in the words of our informer, the agency gets "an unfiltered providers' view of what is actually going on." On the other hand, they are not a workforce advocacy organization either, which helps with their credibility in informing OASAS about the workforce barriers they witness in the field
The resources that CTAC/MCTAC offer the SUD workforce take into consideration the regional differences in delivery systems. This tailored approach helps providers distinguish between statewide and regional policies and practices. They offer group-format in-person trainings in every region, typically attended by 200-250 individuals. The trainings cover a broad range of topics--from administrative and infrastructure changes required by the new system to high-quality service provision, contracting, billing, and performance reporting. In addition to in-person events, the organization offers online trainings, including the Uniform Clinical Network Provider Training, which provides an overview of the expectations for providers under the new system. Since 2014, CTAC/MCTAC has made at least one in-person contact with about 85% of the approximately 900 behavioral health providers in New York; most have been contacted every year.
An important resource for SUD providers, developed through a partnership between OASAS and CTAC, is the LOCADTR tool. LOCADTR is a web-based application that guides providers in determining the most appropriate levels of care for a given SUD. The state strongly encourages all insurers and providers to use the tool in determining the appropriate level of care for their enrollees and clients. Medicaid MCOs are required to use it.
One specific need that CTAC/MCTAC addresses is related to the state's requirement that MCOs provide a training program for their provider networks, to provide appropriate knowledge, skills, and expertise and offer technical assistance in fulfilling managed care requirements. These programs typically offer continuing clinical education and address topics such as co-occurring disorders, cultural competency, evidence-based practices, billing, coding, data interface, documentation requirements, claims submissions, and the service array available to Medicaid beneficiaries. MCOs can fulfil this requirement by having their providers take trainings offered by CTAC/MCTAC. Although the state requires MCOs to make trainings available, there is no requirement for providers to take the trainings; this helps the state provide resources without adding to the prerequisites for joining networks. Providers can also obtain continuing education credits and fulfil some certification requirements through these resources.
The CTAC/MCTAC website archives their training events and makes recordings available for online access. The site also offers online tools, handouts, a list of acronyms, policy guidance documents, and instructional films. An email helpline is also available to respond to questions from individuals and agencies. Over 5,000 messages arrive daily and receive responses within 24 hours, on average. All of these services are offered free of charge and funded by the state.
There is a formal feedback mechanism between the state (OASAS and OMH) and CTAC/MCTAC. The email queries are shared with the state daily. Weekly communications allow the two sides to share policy updates and feedback from the provider side. To solicit input from providers, CTAC/MCTAC also conducts periodic focus groups and makes an annual presentation to state officials. This feedback mechanism allows the state to stay up-to-date on the impact of its policies on behavioral health practice and to respond to challenges in a timely fashion. It also allows CTAC/MCTAC to learn about new and upcoming policy initiatives and to make timely updates to its resource base to help the workforce keep up with a rapidly changing policy environment.
Managed care brings a new set of regulations governing insurance networks, including new contracting requirements and reimbursement schedules. These changes impose administrative and financial burdens on providers that were set up to operate within the old environment. One way in which New York has supported the workforce during the system redesign is through regulating MCOs. The state has a model contract that all Medicaid MCOs are required to use in recruiting providers, including some important safeguards to reduce potential burden on their providers and to facilitate providers' network participation. These provisions can be summarized as follows:
One such requirement is standardized online communication between MCOs and providers. All Medicaid MCOs are required to set up web-based portals to communicate with their networks, eliminating the need for telephone or fax interactions that are more burdensome and not as readily conducive to standard recordkeeping. This requirement streamlines the application, contracting, and reimbursement processes for providers.
Reimbursement for SUD services. Network adequacy regulations include opioid treatment programs as essential services, and prior authorization cannot be required for SUD services. These regulations apply to commercial plans as well as Medicaid plans. All New York health plans now reimburse outpatient, inpatient, or residential SUD services.
"Soft" transition in reimbursement rates. One of the challenges that providers face during the transition from a FFS to a managed care payment model is the lengthy process of adjusting their practice to new reimbursement rates. To ease this transition, New York requires its MCOs to pay outpatient behavioral health providers (licensed or certified) the Medicaid FFS rates for the first 2 years of their joining the MCO's network.
Medicaid MCO contracts restricted to use of Medicaid products. If a Medicaid MCO requires providers to accept pre-negotiated rates for services and supports not covered by Medicaid as a condition of participating in the MCO's Medicaid plans, providers find it difficult to join Medicaid networks. In New York, Medicaid MCOs are prohibited from including such requirements, called "All Products Clauses," in their agreements with providers.
Streamlined credentialing. In some states, MCOs may impose credentialing requirements above and beyond those required by the state, as part of their contracts. These may vary from one MCO to the next within the state, making it difficult for providers to join multiple networks. New York requires its MCOs to accept state licensure or certification as having met the MCO's contracting standards, easing the way for providers to join MCO networks.
Medical necessity and grievance decision facilitators. Obtaining a medical necessity ruling from MCOs can be a time-consuming process and may require several iterations to justify the need for a service. Likewise, providers may also find the grievance process burdensome and lengthy; as with the medical necessity ruling, this process may require several iterations to explain the context for the grievance, to have the grievance reviewed, and to have it acted upon. To facilitate these processes, New York requires that MCO staff involved in medical necessity or provider grievance decisions have clinical experience relevant to the case under consideration.
Strictly speaking, the use of the model contract is a requirement only for Medicaid MCOs; however, OASAS' chief counsel indicated that the state has been "aggressive in getting commercial plans to use state approved model contract language in commercial plans."
Support in Transitioning to a Value-Based Practice Model
Transition to a value-based payment model requires important changes to providers' existing business models, involving administrative and infrastructural adaptations that often require a substantial investment. The transition can, thus, pose important challenges to providers, and especially to small providers with limited resources. Starting in January 2018, the state is making Medicaid funds available to support providers through this transition. Multiple mental health and addiction service providers can join together to form BHCs to qualify for these funds. All members of the collaborative then share in the administrative functions created with these funds, instead of each provider separately investing in the new functions needed for practice transformation. Regional collaboratives can use these funds to:
Identify gaps in the continuum of care they offer and make changes in the practice to offer better integrated care.
Develop new processes for monitoring treatment plans to preempt avoidable complications and avoid unnecessary costs.
Identify and implement opportunities for quality improvement and cost reduction.
Improve information technology capabilities and efficient data sharing mechanisms with multiple providers.
Develop quality improvement protocols to identify and address shortfalls when quality metrics do not meet their targets.
So far, 19 such collaboratives have been awarded. For example, one such network, the South Central Behavioral Health Care Collaborative, was awarded $1.6 million over 3 years to bring together 33 providers in their region to "address identified gaps in services by seeking additional partners who offer those services and working with current partners to expand available services."
Incentives for Hiring New SUD Providers
With the help of funding from the State Targeted Response to the Opioid Crisis (STR), New York makes funds available to provider organizations for offering sign-on bonuses to recruit new SUD staff members. Combined with network adequacy requirements that require the availability of SUD services, these funds encourage networks to expand their SUD workforce capacity while at the same time providing incentives for professionals to enter the SUD field.
Funds available to the 13 CCBHCs in the state through the Excellence Act have also created new avenues for expanding the SUD workforce. A review of the early impact of this initiative by the National Council for Behavioral Health found that gaining CCBHC status helped clinics offer enhanced salaries to hire new staff or to retain existing staff. For example, these newly available funds allow them to hire new prescribers for MAT and to provide peer support services to clients of all ages.
Training and Education Support for Counselors and Peer Specialists
Credentialed Alcoholism and Substance Abuse Counselors (CASACs) in New York are required to complete 60 hours of continuing education every 3 years. The state provides free online training to cover all 60 hours, so that once certified, a CASAC does not need to pay for any further education to be recertified. This is an incentive to join and remain in the SUD workforce.
During the past 2 years, OASAS has also offered scholarships for Certified Recovery Peer Advocates (CRPAs) to complete the required training and take the test for certification. This has had a large impact on the workforce: The OASAS general counsel indicated that the number of CRPAs in the state went from zero to 750 during that period. He added that OASAS is committed to continuing this program because they consider it "a really critical element in what we need to do moving forward."
The state department of health has a loan forgiveness program to encourage medical professionals to practice in high-need areas, with a few slots available for addiction and mental health providers. Additional funds have recently become available through HRSA's National Service Corps to allow additional addiction treatment professionals to take advantage of loan forgiveness. The state is also exploring the option of setting aside some funds from its STR grant for this purpose.
Telemedicine widens a provider's client base without adding commuting burden; the ability to bill insurance for these services is an additional facilitator for providers. In New York, insurance plans are prohibited from distinguishing between in-person care and telepractice in reimbursing covered services. That is, all covered services are reimbursed even if provided through telepractice. Our informants indicated that this has significantly helped expand SUD services to remote areas experiencing provider shortages.
Remaining Challenges and Future Directions
The SUD field in New York is in the process of extensive transformation, opening new professional opportunities for practitioners at multiple levels. The new managed care and value-based payment models being instituted in the state, however, focus on provider organizations as the main actors. New York does not offer a license for SUD counseling, only a certification. It is still not possible for individual SUD professionals to establish independent practices and join insurance networks. SUD practitioners can only get insurance reimbursement for their services as staff members in a licensed facility. This may be a discouraging factor for a student or early-career professional at the stage of choosing a field of specialization. For many professionals, having independent practice at the end of their career ladder is an incentivizing factor. To the best of our knowledge, there are no current legislative efforts to define and regulate a role for independent providers of SUD services within the developing managed care environment. Such efforts may help further bolster the desirability of addiction counseling as a specialty.
The key lesson learned from the successes that New York has had with its Medicaid redesign is the importance of providing support to providers in adapting their practices to the new system. Not only has the state provided supports and resources to providers in bridging the gap between existing business models and the requirements of the new system, it has done so in a timely fashion to preempt undue provider burden and workforce losses. This coordination between system redesign and provision of workforce supports has allowed the state to simultaneously expand coverage for behavioral health services, control costs, and improve service quality without suffering any workforce losses as has been the case in other states transitioning their behavioral health system from FFS to managed care. No doubt, the conscious efforts to learn from the experiences of other states during the planning stages were instrumental in making this a relatively smooth transition for the workforce.