Issue / Description / Response / Position / Priority / Progress

New Jersey Psychiatric Rehabilitation Association

Quarterly Dialogues with NJ Department of Human Services

Issues Discussion Guide and Progress Monitor

DRAFT v.2.3 (with changes tracked from August 22 recommendations of NJPRA Public Policy Committee)

as of November 16, 2018

This document is organized by the following categories of interest to NJPRA:

  1. Workforce Development
/ Issues relating to the recruitment, training, and development of the behavioral health workforce, including psychiatrists, psychologists, nurses, social workers, peer providers, and direct care staff in state hospitals, private hospitals, and community-based agencies and programs.
  1. Agency Development
/ Issues relating to operations of institutions and behavioral health agencies, such as business, finance, marketing, compliance, and administration.
  1. Sector Development
/ Issues relating to theeconomics and administration of the entire behavioral health sector, such as rate setting, service delivery standards and regulations, Medicaid expansion, ACA implementation, Medicaid State Plan waivers, and general public policy matters.
  1. Practice Development
/ Issues relating the science and practice of psychiatric rehabilitation, such as dissemination of the evidence-based and promising mental health practices, research, education, credentialing (especially CPRP), and certification.
  1. Client/Consumer/Family Development
/ Issues relating to the care and concerns of individual service recipients and their families, such as financial supports, other supports, stigma, violence, burden, confidentiality, case management, and legal matters.
  1. Government Development
/ Issues relating to individual entities of the state government engaged in whatever way with mental health issues, including health, finance, housing, programs, education, training, law, and funding.
Issue / Description / Response / Position / Priority / Progress (as of Aug. meeting)
  1. Workforce Development

  1. COLA
/ Governor proposes 0.5% for all non-profits for 2013. /
  • BH workers: no COLA increase in 6 years.[1]
  • PsyR workers earn less than OT workers.
  • For most PsyR workers, 0.5% COLA is like a bonus of only $150, or $3 per week, the cost of a cup of coffee…[Barrett] [2]
  • “Livable wage”:hrly wage or annual inc necessary to cover basic household needs plus all relevant taxes while maintaining economic independence from publicly provided income and housing assistance.[3]
  • Living wage in NJ:1 adult = $11.13per hr. Family of 4 = $21.17 per hr.[4]
  • Avg wage of NJ “healthcare support” = $12.61, BELOW a living wage for family of 4.[4]
/
  • PsyR providers deserve at least a “living wage”.[1]
[What is the average PsyRwage now in NJ?]
  • 2013: Provide COLAs equal to those of state BH workers.
/ A
  1. Use of statistics
/ DMHAS is using statistics such as the median and not the mean of costs of agencies statement [Stivale]. / The process is not transparent. The use of median is not explained or justified. The wide cost variability between northern and southern New Jersey is not taken into account. /
  • The Division should make its statistical processes more evident to the stakeholders.
  • The Division should establish regional rate differentials rather than applying one standard to the whole state.

  1. Salary Parity (with hospitals)
/ Salaries of those in hospital systems are much higher than for community systems. / Community agency rates will not be the same as hospital rates, even for the same services.[2]
  1. Training

  1. State hospital workers
/ State hospital direct care workers = 65% of face time with patients. HST/HSA min.ed. req’t in NJ = not even high school diploma.[5] / NJ’s least educated are caring for NJ’s most vulnerable.
Studies show that a continuing education format can provide portable, low-cost, and effective basic education in psychiatric rehabilitation to entry-level workers.[6] /
  • Require all state hospital BH workers to have CPRPs
  • Arrange and fund CPRP training program for all done by UMDNJ PsyR Department.

  1. PsyR Professional Education in NJ
/ UMDNJ/Rutgers has one of the nation’s best PsyR education programs at all degree levels. It is unique in the breadth, depth, and quality of its work. / The UMDNJ/Rutgers program has positive and immediate impact on PsyR careers.[7] / NJ DMHAS should continually lobby Rutgers to sustain the Department of Psychiatric Rehabilitation.
  1. Community based care workers
/ The direct community care workforce needs more competency to deliver skill-based strategies for training and developing for consumer.
Currently there isstill very little information from DDMHAS about the regs, etc. / DMHAS should provide CSS guidance and regulations immediately.
  1. Social Workers
/ Those doing clinical work are licensed by the Dept Law & Public Safety Div of Consumer Affairs. Require-ments[8]:
  • NJ does not offer reciprocity with other states.
  • Only LCSWs can provide clinical services (e.g., clinical assessment, clinical consultation, psycho-therapeutic counseling and client-centered advocacy).
  • To become LCSW, must first become LSW.
  • LCSWs: NJ requires 1920 clinical hours (within 3 years post MSW).
  • Supervision: only by a LCSW with min. 3 yrslicensure and 20 hrs cont. ed. credits of post-grad course-work related to supervision.
  • Supervision: must be at least once per week face to face.
  • Licenses: must be renewed every 2 years.
/ NJ has among the most restrictive licensing requirements for social workers. Stringent licensing requirements make more difficult the recruitment and retention of LCSWs in community based mental health agencies.
  1. Licensed Professional Counselors (LPCs)
/ LPCs are qualified to provide basic services like assessments that need not require higher credentialed people.
Many LPCs are also addictions counselors. / Rehab counselors should be able to qualify as LPCs.
  1. Peer Providers
/ [Should NJPRA take a position on peer credentialing and licensure?]
  1. Certifcation

  1. Academic degrees
/ The ACA and Medicaid expansion is requiring academic credentials beyond the actual need of some services (e.g., assessment), which will further pressurize the resources and budgets of community agencies. / Within its own discretion, NJ should assure that credential requirements are appropriate for particular services.
  1. Certificate of Psychiatric Rehabilitation Practicioner (CPRP)

  1. Engagement and Deployment

  1. Peer Providers
/ Peer involvement in mental health services is a proven means of reducing rehospitalizations.[9] / The ACA provides many new options for the employment of peer providers. But NJ as a state does not have sufficient knowledge of who and where are the peer providers. /
  • NJ DHS should do an expeditious and thorough census to determine the number of actual and potential peer providers in NJ.
  • NJ DHS should maintain a current and complete registry of NJ peer providers.

  1. Agency Development

  1. Transition Support
/ DMHAS will help agencies transition from contracts to FFS managed care with “deficit funding” by quarters over a year, first 100%, then 75%, 50%, and 25% etc. / One year is too short a time for agencies to adjust from a contract system to a FFS managed care system. Disuptoins will ensue. Clients will suffer. PsyR practice will be degraded. / The transition period should be increased to at least two years.Also,the reduction intervals within the transition period shoud be increased from quarters to half-years.
  1. Investment and Working Capital Support during transition to FFS
/ Under the ACA, BH agencies will berequired to invest in expensive compliance, EMR, training, but as non-profits have no investment capital. / “The conversion to a fee for service presents cash flow poses difficulties for the small nonprofits. Lags between service and reimbursements could be more than one and a half months, meaning that agencies need cash on hand equaling 15 percent of its annual costs to survive the transition.”[1] /
  • NJ DMHAS should adopt a very liberal transition financing policy that enables BH agencies to draw on future payment flows to help finance their current requirements.
  • DMHAS should request and fund a specific fund for agency working capital once contracts begin reducing.

  1. Compliance: Audits
/ “RAC” audits by CMS will be strict, handled in NJ by private contractorHMS for the Division of Medicaid Fraud of the Office of the State Comptroller. / RAC audits seem much stricter than the state’s regional Medicaid auditors. Disparity in expectations of various auditors (Fed or State) is creating conflicts for compliance, as well as significant financial risk for the agencies. /
  • All Medicaid auditors, be they RAC or state, should be coordinated, so that agencies can know better what to expect and thus better and more easily to comply
/ [Green] DMHAS is coordinating with Medicaid central office. “I’m very interested to bring them back this feedback.: Need to connect with Steven Tahney (sp?).[2]
  1. Training about Community Support Services standards (CSS)
/ DMHAS’s intent is that all will be able to bill for community based services (e.g., ICMS, PACT), not just supported housing. / Re: the Wellness Transformation… An LSW may not have the PsyR training. How to preserve and advance PsyR? [Stivale] [2]
Community based services delivered off-site (not in the clinics) are important components of PsyR and should be supported as such by inclusion in the Medicaid rate setting. / Community based services should be supported by Medicaid rates. / Finalizing a contract with SHRP for 2 tracks: supervisors (2 regions) and direct care (3 regions). To get individuals to learn and understand was CSS is. “We agree with you that there are a lot of providers who think they are providing the service but are really not…” [Larosiliere] [2]
  1. Sector Development

  1. Hagedorn Funding Reinvestment
/ Annual NJ Budget Appropriation Bill constitutes a law that supersedes NJ Community Mental Health and Developmental Disabilities Investment Act.[P. Lubitz] / $41 mm of savings achieved from H. closing. Consistent with NJ Community Mental Health and Developmental Disabilities Investment Act (“… to provide for a process by which the resources which result from the sale of residential facilities and/or the reduction of expenditures for State inpatient resources shall be invested in community-based services…”[10]), all this should be redeployed to fund MH/DD community services. But only $.4.4 mm going to community services.
A previous legislature cannot bind a current legislature. [Joe Young]. / NJ shouldabide by the spirit of the NJ Community Mental Health and Developmental Disabilities Investment Act. It should redirect all H. funding to community based mental health services generally to needs such as: service rate support, worker living wage support, agency working capital transition support, and outcomes measuirement capacity building. / A / Only $500,000 of H. funds are being reallocated to Supported Employment funding Beyond this, no avoided H. operating funds are being specifically allocated (are have been assured) to community mental health. DMHAS however expects an asset in FY 2014 to a request for new budget allocations “to grow”.[2]
  1. Comprehensive Waiver Implementation

  1. Medicaid Related

  1. Rate Setting
/
  • Consultant (Myers & Stauffer, CPAs) hired.
  • Base year to be used: 2012.
  • Cost-based.
  • Agencies, other states to be analyzed.
/
  • NJ Medicaid rates: LOWEST IN THE COUNTRY (Medicaid/Medicare ratio: US = 72%; NJ = 37%) [11]
  • The Medicaid/Medicare rate ratio is still low, though improving slowly. [11]
  • 60% of NJ physicians will not accept new Medicaid patients (US avg = 30%).[12]
  • Base year 2012 is worst year of major recession.
  • Rates should fully cover all costs of doing business in a fee-for-service regime.[1]
  • Rates should account for regional cost differences within the State (e.g., rural vs. urban, north vs. south).[1]
  • The broadest criteria for determining income eligibility should be used esp. for those without Medicaid.[1]
/
  • Delay implementation
  • Pick a better base year
  • Increase transparency
  • Provide for evaluation
  • Rates, when set, should be flexible for subsequent revision and reconciliation with evaluation
/ A / Myers & Stauffer will seek info from 7 “practice groups”:
  • Outpatient
  • Partial care
  • Residential (incl. detox)
  • Methadone
  • Case Management
  • PACT
  • Supportive Housing
Also, specific agencies to be visited.[2]
  1. Rate Uniformity

1)Geographic variability of rates / Rates are to be uniformly around the state, regardless of location. /
  • NJ DOL statistics suggest extensive variability in cost-related factors across NJ.[13, 14]
  • Population density (urban vs. rural) “definitely” affects cost. Ex: Bridgeway: $45 per unit in Union; $65 per unit in Sussex.[2]
/ Generally, rates will not vary by region to account for regional cost differences.[2]
Rates may vary between scatter-site and single-site facilities.[2]
How to reckon screening cost differences between psych hospitals (e.g., Greystone vs. Ancora): no clear answer received.[2]
2)Population variability of rates / Rates to vary according to particular needs of “vulnerable” populations (?) / In FFS model, core services “with enhancements” to be purchased differently for vulnerable populations, e.g.: a) Medical fragile or compromised
b) Deaf and hard of hearing, c) Children (Provision of EBPs for child welfare) [Green].[2]
3)Service variability of rates / Billable services without different serfvices (e.g., ICMS, PACT, Partial Care, SuppHous, SA, Residential vs group homes,etc) are very different. [Stivale] / NJPRA urges that the system get to capitated rates as soon as possible.
4)Provider variability of rates / The size of providers must be taken into account, since their cost bases are vastly different. [Stivale]
  1. Rate Basis
/ Comprehensive Waiver proposes to move behavioral health to a managed care approach—at first on an encounter-basis fee-for-service basis. / Fee-for-service encourages service overuse and does not provide for care over a continuum.[15]
When moving to managed care, why must NJ BH managed care be first on a FFS basis, which seems a step backwards?
]. /
  • Rates should provide for continuum of care, not by fee for service but by case rates and, better yet, capitation rates.
/ DMHAS believes it must first start with smaller blocks (FFS) before going to capitation since there isn’t enough “encounter data”. [Green] [2]
1)Data Gathering and Quality / The M&S cost determination tool is inadequate, because it doesn’t account sufficiently for provider, service, geographic, and client demographic variability. Data is also outdated (3 years old). Explanatory qualifative analysis is lacking. [Stivale]
The selection of providers for data gathering is not fully known or understood. [Stivale] / M&S must refine its tool to capture all variability and true agency costs.
DMHAS should post the details about who the providers selected are and how they were chosen [Barrett].
  1. Covered Services

1)Promotion of integrated PH/BH services / As NASMHPD [16]recommends: Medicaid should:
  • Provide coverage for health education and prevention services (primary prevention) that will reduce or slow the impact of disease for people with SMI.
  • Establish rates adequate to assure access to primary care by persons with SMI.
  • Cover smoking cessation and weight reduction treatments.
  • Use community case management to improve engagement with and access to preventive and primary care.

2)Services not covered by Medicaid / Will this include the Self-Help Centers now be covered directly by the State?...
What about SuppEmpl?
What about SuppEd?
3)Medicaid plans: legacy vs. “benchmark” / Medicaid benefits after expansion will increase… / No, they won’t… Benefits under The ACA’s Medicaid expansion will be fewer for “new eligibles” to be enrolled than for those already covered by legacy Medicaid. Substance abuse benefits are particularly affected.[17] / For “new eligibles” with psychiatric disabilities to be enrolled in “benchmark” plans in Medicaid expansion with fewer benefits than for existing beneficiaries, the state should provide whatever benefits not covered by benchmark plans but covered by legacy Medicaid plans. / DMHAS may not understand this point fully. Medicaid “benchmark” plans after expansion in fact will offer fewer benefits than legacy Medicaid plans.[2]
[But, is State considering to increase certain benefits on its own?]
  1. “Medical necessity”
/ This CMS term, a relic of the “medical model”, is too narrow for proper PsyR. / [What is covered in the “rehab” option?]
Key terms need clarification, notably the State’s definition of “serious mental illness.” [Barrett] /
  • Expand NJ state definition of “medical necessity” to include for those with psych-diabs all aspects of PsyR EBPPs (esp. Supportive Housing)

  1. Expansion
/ Currently 1.3 mm in NJ get Medicaid. ACA expects to increase NJ enrollment by 234,000, or ~23% (only 46% of NJ’s currently uninsured).[18]
1)Outreach and recruitment /
  • CMS to train 3 classes of recruiters (e.g. Navigators, Assisters, Certified Enrollers). See
/
  • Wherever possible, peer providers should be hired to recruit non-insured New Jerseyans into Medicaid.
/ DMHAS is working with Medicaid to expand capacity for assister training, for providers to attend and become certified. One day training to become a certified application assister.[2]
a)ACA Navigators / CMS has awarded $2 mm in grants to 5 Jersey entities:
  • Center for Family Services (Camden, southern counties)
  • Wendy Sykes - Orange ACA Navigator Project (Essex)
  • Urban League of Hudson County
  • Public Health Solutions (NYC, serving Hudson, Essex)
  • FoodBank of Monmouth and Ocean Counties
/ CMS awards heavily target only certain locales. What special efforts to recruit those with psych diabs? / DMHAS should ensure outreach to those with SMI not insured.
  1. Provider Networks
/
  • 60% of NJ physicians will not accept new Medicaid patients (US avg = 30%).[12]
  • ACA’s “rate bump”: only 2 years, only for PHPs. No bump for BH providers.[19]
/
  • Insufficient PHP provisions to increase providers to meet the expansion
  • BH providers reducing!
/
  • Increase Medicaid rates by [x] %, sufficient to increase the percentage of NJ providers accepting new Medicaid patients to at least the national average (70%).

  1. Community support services (CSS)
/ CMS approved specific details for CSS items to be covered by Medicaid.[20] / The CSS regs draft now done internally. Needs review and approval outside the Division before being available for public comment. By the end of 2013, we hope they will be published. Public comment will follow in 1stqtr FY2014.[Larosiliere][2]
In addition to training for clinical support for CSS, DMHAS is getting some tech assist related to separation of housing and services. Consultants are doing a readiness review and a work plan.[2]