Posted May 31, 2011
The organizational structure of behavioral-health-care services soon will change to focus on recovery and wellness — as opposed to treating illnesses.
In the past, a minuscule part of the Medicaid-insured population — primarily, those with mental-health diagnoses or substance-abuse problems — had absorbed a disproportionately high amount of money from the system because of repeat hospital visits that treat illnesses at the expense of exploring long-term recovery options.
“If they’re not in the hospital, they’re using more outpatient services,” said Roger J. Ambrose, Jefferson County Community Services director. “This is all to improve their recovery, to try to keep them out of the hospital.”
The state Medicaid program paid out $4.9 billion in hospital claims for patients who were readmitted to a hospital within 31 days of being discharged, according to a 2009 report from the state comptroller’s office and Division of State Government Accountability.
That report, “New York State Department of Health: Medicaid Overpayments for Hospital Readmissions,” highlights the need for the state Department of Health to effectively manage the Medicaid system.
Mr. Ambrose said one way to do that is to focus on long-term wellness over short-term Band-Aids.
He said the new model of care will create a win-win situation for patients and government agencies that would save money by not having to put as much into the Medicaid pot. Also, by treating patients more efficiently, the state could become eligible for supplemental federal funds.
Harvey Rosenthal, executive director of the New York Association of Psychiatric Rehabilitation Services, said the evolution of behavioral-health services has been a long time coming. Shifting the focus away from solely treating illnesses began in the 1970s, though it’s expected to speed up rapidly over the next few years. He cites the evolution of behavioral-health care:
— In the 1970s, medical providers to patients with psychiatric diagnoses focused on medicating patients too much, he said.
— In the 1980s, an emphasis was placed on placing patients in sheltered workshops, which provide employment opportunities for those with disabilities.
— In the 1990s, those deemed “high functioning,” largely because of medication advances, were met with rising expectations about work and home lives.
The Medicaid system hasn’t kept up with those improvements in behavioral health care, Mr. Rosenthal said.
“We went from psycho-social clubs, and we’ve just blossomed from that to be peers and providers from throughout the state fighting for rights,” he said.
Moving into the 2000s and today, he said, providers have begun to help patients focus on goals using so-called “person-centered planning,” while overseeing agencies began to make moves toward restructuring clinics so patients, providers and the health-care system are operating on the same page.
The state hopes the Medicaid system will be caught up by 2014.
Mr. Ambrose said there would be a few behavioral-health organizations in the state, run much like a health maintenance organization, or HMO, that would act as a Medicaid fund system, which involves the inclusion of all aspects of a person’s care needs.
“I think all the pieces are here, but they don’t work together well,” he said, regarding various agencies that offer behavioral-health services. “We’re going to need cooperation from all organizations. Every one runs a little piece, but they don’t always work together.”
This new model will begin to take shape in the community when the Children’s Home of Jefferson County replaces Mercy Behavioral Health and Wellness on July 1 with its own clinic. Children’s Home Executive Director Karen Y. Richmond had said that model eventually will become all-inclusive.
Mr. Ambrose said the community has all of the pieces to make these changes, but agencies that offer the same or similar services need to either collaborate or consolidate to make those changes happen.
Some details are being left to be made at the local — not state — level, Mr. Ambrose said.
“They’re going to have to start talking to clients right away,” he said. “Their expectations of client participation in this will be higher — that they make their appointments, take their medications, and there will be some who have a very difficult time with that.”
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Copyright © 2011, Watertown Daily Times, N.Y.