Regulatory Modernization Initiative Update

Dan Sheppard, Deputy Commissioner
Office of Primary Care and Health Systems Management

  • Update is also available in Portable Document Format (PDF)

All PPS Meeting
September 11, 2017

Regulatory Modernization Initiative

Goal: Modernize the State´s health care regulatory structure to better align with and foster health system transformation. Focus on core purposes of ensuring access, protecting patient safety and meeting community needs

Approach: Convene issue–specific workgroups of providers, payers and consumers

  • Nimble and transparent
  • A process, not a singular project
  • Two sessions for each issue: 1) barrier identification; and 2) solution(s) option development

Timing: Phase I workgroups completed by end of CY 2017

Phase I Topics: Important and Urgent

  • Integrated Primary Care and Behavioral Health Services (underway)
    • Basic Primary Care
  • Telehealth (underway)
  • Post–Acute Care Management Models (underway)
  • Long Term Care Need Methodologies (to be scheduled)
  • Cardiac Services Need Methodologies (to be scheduled)

Integrated Primary Care and Behavioral Health Services

Goal: Truly integrated care elevates the level of care and results in better outcomes. There should be "no wrong door for patients", particularly patients with chronic physical and behavioral health conditions

Barriers/Concerns:

  • Still three separate sets of licenses, regulations, billing methodologies and oversight for primary care, mental health and substance use disorder (SUD) services
  • Physical plant standards for primary care difficult to achieve for many mental health and SUD clinics
  • Workforce (scope of practice, supervision requirements)
  • Scale to make primary care financially viable
  • IT/medical records infrastructure to make care coordination possible
  • Continuity with Primary Care Provider (PCP)

Proposed Integrated Services

"Basic" Primary Care Services Mental Health Services SUD Services
  • Primary care services (all ages) including health promotion, family planning services, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment (traditional and/or alternative) of acute and chronic illnesses (optional service) and the utilization of consultation/referral as appropriate.
  • Vaccinations
  • Screenings
  • Diabetes outpatient self–management training (DSMT) services (smoking cessation, other self–management training services)
  • Medical nutrition therapy (MNT) services
  • Diagnostic testing (phlebotomy)
  • Procedures
  • May perform non–invasive procedures normally performed in an outpatient clinic setting.
  • Sedation (no more than local anesthesia may be provided)
  • Health home
  • Medical reconciliation, care coordination, social determinants of health services (housing, educational, etc.)
 Required services:
  1. initial assessment (including health screening).
  2. psychiatric assessment.
  3. crisis intervention.
  4. injectable psychotropic medication administration (for clinics serving adults),
  5. injectable psychotropic medication and administration with monitoring and education (for clinics serving adults);
  6. psychotropic medication treatment – clozaril optional under proper supervision/monitoring
  7. psychotherapy services
  8. family/collateral psychotherapy
  9. group psychotherapy;
Optional services:
  1. developmental testing;
  2. psychological testing, including neuropsychological testing?;
  3. health physicals;
  4. health monitoring;
  5. psychiatric consultation; or
  6. injectable psychotropic medication administration (for clinics serving only children);
  7. injectable psychotropic medication administration with monitoring and education (for clinics serving only children);
  8. Peer services.
 Required services:
  1. pre–admission assessments (including gambling screening, communicable disease and screening and testing).
  2. recommended & required toxicology and testing (HIV/HCV/TB)
  3. physical assessment and referral or exam
  4. psychiatric assessment.
  5. individual and group counselling
  6. treatment and recovery planning
Optional services:
  1. brief intervention
  2. brief treatment
  3. collateral services
  4. complex care coordination
  5. outreach
  6. peer services;
  7. screening
  8. medication administration and observation
  9. medication assisted treatment
  10. intensive outpatient services
  11. ancillary withdrawal only with appropriate designation

Telehealth

Goal: Telehealth is widely recognized as an important tool in achieving Triple Aim objectives. Realize full potential of modality by aligning NYS's regulatory framework with "real world" implementation strategies and technology

Barriers/Concerns:

  • State agencies have varying an distinct regulations rules and policies
  • DOH reimbursement focused and treats telehealth as a service; OMH, OASAS and OPWDD approach telehealth as a tool or modality for providing services
  • Statutory limitations on "originating site" (Medicaid)
  • Widely varying standards between commercial plans for reimbursement
  • Credentialing/Privileging
  • Keeping PCPs in the loop

Post–Acute Care Management Models

Goal: Develop a statutory and regulatory framework that supports high–quality, patient–centered post–acute care models

Barriers/Concerns:

  • Lack of coordination between hospitals and home care agencies
  • Difficulties securing immediate home care services through established agencies for patients in the immediate hours/days following discharge from hospital
  • Workforce shortages in some regions
  • Insufficient HIT infrastructure to efficiently and effectively connect hospitals and home care providers

Long Term Care Need Methodologies

Goal: Develop new need methodologies for long term care and support services that focus on community need and age friendliness

Barriers/Concerns:

  • Current need methodologies do not take into consideration the array of LTC services available in a community or region (residential, home and community–based)
  • Current nursing home need methodology does not distinguish between post–acute and long–term beds

Cardiac Services Need Methodologies

Goal: Ensure that emerging regional networks of care can offer a full array cardiac services to their patients while protecting patient safety, maintaining access for vulnerable populations and controlling costs

Barriers/Concerns:

  • The facility–specific volume requirements within the existing regulations for cardiac catheterization (PCI) procedures are outdated based on medical advances and in the context of regionally integrated health care systems
  • Restricting services within a geographic planning area as a means of controlling health care costs may no longer be necessary given the move toward care management and risk–/value–based payment systems
  • If expansion of specialty services is permitted in a planning area where projected utilization can be accommodated by existing providers (i.e., there will be winners and losers), measures will need to be taken to protect access to essential health care services for economically or geographically vulnerable populations

Regulatory Modernization Initiative