The past few years have seen the move of many payers and health plans to “integrating” behavioral health. Models that have separate, “carved out” behavioral health financing and delivery are being replaced by models that integrate all service financing and delivery in one managing entity.
What does this look like in Medicaid? As of January 2020, approximately 69% (50.2 million) of the 72.8 million individuals in Medicaid were enrolled in integrated behavioral health financing arrangements—a slight increase over 2019 when 64% were enrolled (see State Medicaid Behavioral Health Carve-Outs: The OPEN MINDS 2020 Annual Update). Additionally, 31% (22.3 million) were enrolled in traditional specialty carve out plans, and less than 1% (326,000) were enrolled in a vertical consumer-specific specialty health plan. Comparatively, in 2017, approximately 56% (30 million) of the 53.6 million individuals in Medicaid were enrolled in integrated financing arrangements (see State Medicaid Behavioral Health Carve-Outs: The OPEN MINDS 2017 Annual Update).
There are currently 31 state Medicaid plans that utilize integrated financing of behavioral health. This list includes Washington State, which completed its implementation of integrated financing this year.
So, from a payer perspective, what goes into the decision to move from one model to the other and what are the elements needed for a successful transition? We were fortunate enough to have a conversation with MaryAnne Lindeblad, Medicaid Director, Washington State Health Care Authority (HCA). She discussed the statewide transition from a nine-region system with county-centered behavioral health care authorities, to one where managed care organizations (MCOs) in each region integrate physical and behavioral health for all Medicaid consumers (see Washington State Health Care Authority Value-Based Road Map, 2017-2021 and Washington State Senate Bill 5432 Of 2019, Behavioral Health Integration).
Starting in 2016 and ending in 2020, the HCA implemented (by region) fully integrated managed care, an approach under which MCOs provide physical and behavioral health services. Washington State also contracts with administrative service organizations (ASO) for the delivery of crisis services (see Exploring The Impact Of Integrated Medicaid Managed Care On Practice-Level Integration Of Physical And Behavioral Health). The state’s 1115 Medicaid Transformation waiver established nine Accountable Communities of Health (ACHs) that assisted in the implementation of the transition plans—including supporting transition efforts, and collecting data for needs, quality, and utilization. Ms. Lindeblad explained that the goal is the link to quality and/or value by 2021.
So, what were her perspectives on the keys to making this transition happen—successfully—for consumers? The immediate goal, according to Ms. Lindeblad, was to determine how behavioral health and primary care can work effectively at the community level to treat consumers much more holistically than they are currently treated today. From our conversation, four key elements stood out—estimating the behavioral health service needs of the community, understand integration and managed care, focus on quantifying outcomes, and developing a plan for interoperability and data exchange.
Estimating the behavioral health service needs of the community—It is important to be both practical and realistic when assessing what can be integrated and how. Most markets will need increased consumer access to services, but beyond making sure they get services, it’s important to prioritize delivery goals. Can provider organizations make sure consumers are getting follow-up services? Is there a need for specialty services like addiction treatment or medication assisted treatment (MAT)?
Understand integration and managed care—As the saying goes, “you don’t know what you don’t know,” which goes for both the state and health plans pushing for integration and managed care. This opens an opportunity for provider organizations who can be the “expert” on integration. First, this gives provider organizations the necessary skill set for signing a contract for integrated services. Second, it allows them to cover their own bases in terms of asking for the necessary support. And third, it allows them to understand the daily business of running integrated service lines.
Focus on quantifying outcomes—When planning a transition, or even when one starts, many executives look at things more anecdotally by going out and getting individual consumer stories. This can be positive, but how do those stories help consumers stay in housing, in employment, or reduce emergency room use and lesson the pressure on the health care delivery system? To do that, provider organizations need to collect and master the use of data to demonstrate the cost effectiveness and long-term ability to maintain their program.
Developing a plan for interoperability and data exchange—Whenever an integrated system comes on line, there will be those provider organizations that need extra support and training, and then there will be those that are already prepared to adapt to the new tech-based requirements. The quicker a provider organization can adopt and/or adapt to the new requirements, the faster they can show positive results and the faster they can be more competitive. Any move to integration will involve a big push in health information sharing and advancing technology at the local level.
These four elements are a good guidebook on how provider organizations can learn to work more effectively with whatever “authority” ultimately leads the charge for more integration in their market (whether that is the state, a health plan, managed care, etc.).
The main strategic problem for many provider organizations operating amidst this change is that many “traditional” ways of doing business are now out-of-date as states and health plans rethink how integration fits into their plans.
As the market pushes for more “value,” payers and health plans are looking for new opportunities to reduce overall costs; integrated models of care coordination that address physical health, behavioral health, and social support services are one possible way to do this. And if you think you can avoid this shift, maybe you can, but I doubt it. Consider that managed care now covers 73% of the insured population in the U.S. (see U.S. Population Enrolled In Managed Care, 2011-2018: An OPEN MINDS Reference Guide), and the effect of this is a shrinking of where “integration” isn’t the market reality (see Integration Model Decisions Are Strategy Work At Its Most Fundamental).
For many organizations, integration has become the “necessary” strategic positioning that is both most sustainable and provides a “preferred status” in a “coordinated” system of care. For more on mastering integration, check out these resources from The OPEN MINDS Industry Library:
- Developing Strategies To Address Integration—The Key Is Market Math & Innovative Value Propositions
- The Changing Shape Of ‘Integration’ In The Complex Consumer Market
- Ten Integration Models Reshaping Specialty Service Delivery
- Making The Many Models Of Integration Work
- The Changing Face Of Integration
- Integration Strategies For The Complex Consumer Market
- Tech Capabilities In An Era Of Integration & Value
- For Successful ‘Integration’, It Takes Interoperability & Patience
- Integration, Interoperability & Consumer Engagement
- Integration—Strategic Threat (& Opportunity) For Specialists
For a deeper dive into the changing roles of primary and specialty behavioral health care, as well as case studies in integration, check out my presentation, The Integration Imperative: What You Need To Know & Do To Remain Relevant. And to learn more on adjusting to a changing market, join us on July 9 for the web briefing, Opportunistic Business Development – Responding To New Market Needs, Quickly.
And finally, be sure to join me for Ms. Lindeblad’s keynote, “Integrating Behavioral Health In A Fragmented World”, on August 26, at The 2020 OPEN MINDS Management Best Practices Institute in Newport Beach, California.