Governor Andrew Cuomo’s Medicaid Redesign Team (MRT) knocked off early yesterday after identifying $2.3 billion savings almost a full week ahead of schedule. The vote on a package of 79 individual proposals – including a global Medicaid cap, 2% across the board cuts and much, much more – came as a surprise to both outside observers and at least some MRT members. The group had originally planned to spend yesterday and today discussing individual proposals and vote on a final package on March 1st – next Tuesday.
Many of the 79 proposals to “redesign and restructure” Medicaid represented conceptual goals or statements of strategic intent. Much of the meat of the MRT’s work remains to be fleshed out in the form of concrete policy and regulatory changes. The new global cap on Medicaid which would limit State expenditures to $15.109 billion and restrict future growth to 4% annually, for example, will entail a variety of monitory and enforcement mechanisms that have yet to be spelled out in detail. Similarly it remains unclear whether the 2% across the board reduction in Medicaid spending will be met through a range of program cuts already proposed as part of State agency spending plans – outside of the MRT process – or would require a 2% across the board reduction in rates paid to providers.
Behavioral health and substance abuse service providers were pleased that the package included a proposal to implement Regional Behavioral Health Organizations to coordinate care for individuals mental health and substance abuse disorders. These individuals are currently “carved out” of mainstream Medicaid Managed Care plans.
“We are grateful that amidst a very unpredictable MRT process, one of the outcomes is approval of plans for a Regional Behavioral Health Organization carve out,” said Harvey Rosenthal, Executive Director of the New York State Association of Psychiatric Rehabilitation Services. “The alternative, which would have turned over the care for tens of thousands of New Yorkers with serious needs to generic health plans, would have been disastrous for them and for the community recovery network we have worked so hard to build. This design should bring us to a more integrated behavioral health system that links healthcare, housing and supports. We look forward to helping to shape that system.”
“This is a victory,” said Philip Saperia, Executive Director of the Coalition of Behavioral Health Agencies. “It was very important that these services did not get folded into the Medicaid Managed Care plans.” At the same time, however, he stressed that there were considerable details yet to be worked out with respect to how RHBOs would be structured. “We are going to get time to plan the next phase,” he said. “It is important that we are at the table during that planning process.”
Providers and advocates did raise concerns about several other proposals.
One would impose utilization controls on behavioral health clinics and reduce reimbursements levels if patients exceeded specified numbers of visits during a 12-month period. Claims that exceeded a lower threshold number of visits would be paid at a 25% discount. Claims that exceed the higher threshold would be paid at a 50% discount. The current proposed lower and higher threshold levels of annual visits are 65 and 85 for OASAS programs, 30 and 50 for OMH programs and 90 and 120 for OPWDD programs. “This is awful,” said Philip Saperia. “This means that certain high needs children and adults may not receive the care they need… or that services will have to be provided at less than the actual cost. This is a rate cut.”
Advocates also expressed concerns about a proposal that would restrict patient and provider choice with respect to behavioral drug choices.
Yesterday’s vote on the package of proposals had not been expected by providers and advocates. And, two MRT members objected to the decision to end discussion – and possible further modification – of proposals which had not previously been seen as a complete package of recommendations. Team members had initially scored a package of 49 preliminary proposals, many of which were dropped from the staff recommendations presented for consideration yesterday. As a result, more than half of the recommendations in the final package had not been rated by the Team members prior to yesterday’s meeting.
Assembly Member Richard Gottfried said that he was “shocked… At the end of our first and it appears only opportunity to ask questions and talk in an open forum… to be told there will not be an opportunity for any modifications in the plan before a vote… I think it is inappropriate.”
Lara Kassel, Coordinator of Medicaid Matters New York, also objected. “I feel unprepared and extraordinarily uncomfortable… I walked into this meeting today thinking this was a two day discussion with an opportunity for a few days to mull things over, talk to some partners, consider some of what is in the package, consider what a yes or no vote would mean.”
Other MRT members felt that it was time for a vote. “A lot of work was done over the last two weeks to bring the package into line with concerns that had been expressed,” said Ann Monroe, President of the Community Health Foundation of Western New York. “When it comes to an up-or-down vote, I ask myself whether there is anything in the package that would cause me to vote the whole thing down. The answer was no.” Monroe argued that the MRT had been able to reach its target without recommending any real cuts to eligibility or services – things which have been implemented in other States.
Ed Matthews, CEO of UCP of New York City, agreed. “The proposals that we had scored lowest — the real ‘deal breakers’ that would have made Medicaid recipients second, if not third class citizens – had been dropped from the package. People were talking about process, but I didn’t hear people say they had different ideas. Most of us didn’t see where more debate would have gotten us to a different outcome.”
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