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Reaching this goal is an important part of the Cuomo administration’s Medicaid Redesign initiative, set in motion to reduce the state’s disproportionate Medicaid expenditure. By doing so, NYS will join with the many other states, including Kentucky, Tennessee, Illinois, and Florida which have taken this step. To its credit, NYS did not rush to make the change prematurely but is now forging ahead rapidly. It started by designating regional Managed Behavioral Health Organizations (MBHOs) to gather data about the residual Medicaid Fee for Service population’s use of mental health services and provide the state with specialty behavioral managed care experience. The expectation is that the information obtained will help shape the managed care model to be created. While this is a good plan we think that the state should also be collecting similar data on those consumers with MHSU Disorders who have been receiving their behavioral care within the MMCPs. Data collected in many states show that there are more patients being treated within the general medical system as compared to the specialty behavioral system even when the behavioral benefit is “carved out “. The state has signaled that it would like to move all behavioral care under the broader Managed Care Organizations (MCOs). The actual clinical outcomes of this devolution to MMCPS remain to be ascertained. Nationwide it is not uncommon to have Medicaid MCOs manage a limited Mental Health/Substance Use (MHSU) Disorder benefit. However moving very vulnerable persons with serious and persistent mental disorders (SPMIs) into MMCPs carries a greater risk for these enrollees than for those whose use is more limited. Based on the NYS experience and that in other states with MHSU Disorder managed care, the concern of patients, families, providers and advocates seems well justified. I am very pleased that Dr. Henry Harbin has agreed to coauthor this article with me because he knows the subject of behavioral managed care as well as, and perhaps better than, most others. The reason that his thoughts on this subject are so highly valued is that he served as the CEO of 2 national managed behavioral health care companies, Greenspring Health Services and Magellan Health Services, which at the time was the largest nationally with 70 million covered lives. He spent 10 years in the public mental health system in Maryland including serving as its Commissioner of Mental Health. Also, he served as a Commissioner on the President’s New Freedom Commission during 2002–3. He has been an early proponent for improved integration of mental and general health care. Dr. Harbin has had experience with Medicaid management models in many states. He informs that there is little to no scientific evidence that moving the SPMI cohort into Medicaid MCOs will improve their clinical outcomes or reduce costs. He explains that states may undertake the transformation to entirely managed systems for financial, organizational, or clinical reasons. The consequence for enrollees may well depend on which motivation primarily drives the change. It is our purpose in this piece to articulate principals based on which consumers, their families, providers, and advocates will be able to make informed judgments about the managed care scheme the state lays out for the care of those with significant mental health care needs. The following are some matters worthy of consideration: Part of the problem is that administrators and planners confuse administrative and financial integration with clinical integration. The field now has a solid research base that supports a clinical evidenced based model called “Collaborative Care for Mental Health in Primary Care”. It is effective both in terms of significantly improved clinical outcomes but also in reducing medical costs. Most of this research was done with MHSU Disorders in the mild to moderate levels of need. There an increasing research base suggesting that this clinical model works with more serious conditions as well. This clinical model works whether the financial management of the entire healthcare benefit is under a single insurance entity or separate entities including MBHOs. For an insurer to implement an evidenced based Collaborative Care program requires flexible reimbursement of several key services and most of the cost savings accrue due to reduced medical, not behavioral, costs! One of the approaches that interested parties in NYS could advocate for during this period of transition would be that NYS DOH require all Medicaid MCOs to begin implementation of the Collaborative Care Model for non SPMI MHSUD patients who receive part or all of their behavioral care within primary care setting. Most of these patients never receive treatment within the specialty mental health system. This would allow the state and advocacy organizations to judge the competence and effectiveness of a Medicaid MCOs to improve the outcomes of the MHSUD patients that are already under their management authority before moving SPMI patients who require a more complex set of interventions under their span of control. If an MCO is unwilling or unable to implement a well documented clinical intervention that is low cost and effective then it is unlikely they will be able to manage a more complex set of patients. Other questions to ask will be: If the proposed system is to serve persons with SPMI well, advocates should only be satisfied if these and other targeted questions are asked and affirmatively answered. Some of these questions can be answered now before rolling the dice and transferring all patients if the state would require the MMCPS to produce clinical and financial data on how well their current population of patients with these problems are being handled. |