NYAPRS Note: The following excerpt comes from a report, “State Options for Integrating Physical and Behavioral Health Care” that was developed for CMS by the Center for Health Care Strategies and Mathematica Policy Research. The report analyzed state options for integrating physical and behavioral health services within managed delivery systems, and looked at 4 integration models, “with various lead organizations serving as the core integrated care entity, including
(1) managed care organizations (MCOs);
(2) primary care case management programs (PCCMs);
(3) behavioral health organizations (BHOs); and
(4) MCO/PCCM and BHO partnerships as facilitated by financial alignment.”
In this e news, we are excerpting the analysis given to the option where Behavioral Health Organizations take the lead role and contract with state Medicaid authorities to provide BOTH physical and behavioral health services for those with ‘serious behavioral health needs.’
We do so to keep current with the advocacy originated last year by 41 NY statewide and regional groups who were seeking alternatives to full integration by managed care organizations (option 1). To see the entire report, please go to http://www.integratedcareresourcecenter.com/pdfs/ICRC_BH_Briefing_document_1006.pdf.
These options will be fully explored at NYAPRS’ upcoming Annual Executive Seminar, to be held in just a few weeks, at March 29-30 at the Hotel Albany (formerly Crowne Plaza). Please see the attached program for dates and times of our panel discussions with representatives of both Behavioral Health and Managed Care Organizations, along with a state panel that will feature Medicaid Director Jason Helgerson, OMH Commissioner Michael Hogan and OPWDD Commissioner Courtney Burke. Register today at http://www.nyaprs.org/conferences/executive-seminar-2012/!
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State Options for Integrating Physical and Behavioral Health Care
By Allison Hamblin, Center for Health Care Strategies; and James Verdier and Melanie Au, Mathematica Policy Research
Integrated Care Resource Center October 2011
Option #3: Behavioral Health Organization As Integrated Care Entity
Description
Behavioral health organizations (BHOs) have specialized capacity around managing behavioral health services, particularly for individuals with SMI. Thus an alternative to integrating care through MCOs is to contract with BHOs to provide both physical and behavioral health services for individuals with SMI or other serious behavioral health needs. In this case, the state, through partnership between the Medicaid agency, the state mental health agency, and other relevant purchasers of mental health services (for example, county-level administrators) would contract with one or more BHOs to manage both sets of services and associated provider networks. To the extent that participating BHOs have the requisite experience and capacity, states can hold the plans at full risk for managing the full array of services. To date, there are no examples of a Medicaid BHO that is responsible for all behavioral and physical health services for enrolled beneficiaries, but some states, such as Arizona and Massachusetts, are currently pursuing such models. As illustrated in the Iowa example below, these efforts may begin with pilot collaborations between BHOs and physical health providers, with the hope that more comprehensive integration can be built on that experience.
Examples
Full Risk for both Behavioral Health and Physical Health: Arizona is currently considering this model for a future reprocurement of its Regional Behavioral Health Authority (RBHA) contract in Maricopa County. Under the proposed model, one or more “specialty RBHAs” would manage all physical and behavioral health services for Medicaid beneficiaries with SMI in the county, under the single authority of the State’s behavioral health agency. The State envisions that the specialty RBHAs will be closely connected to newly authorized Medicaid health homes for individuals with SMI, enabling coordination and integration of physical and behavioral health care services at the provider level. Given that approximately 50 percent of beneficiaries with SMI in this region are dual eligible, the State further intends for the new specialty RBHAs to be MA-SNPs. The State does not intend to allow the RBHAs to subcontract for any subset of the services provided. Conceivably, future bidders could be BHOs that build internal physical health capacity or MCOs that develop or expand internal behavioral health capacity. As of August 2011, Arizona is collecting responses from prospective bidders on a recently released Request for Information, with implementation slated for October 2013.
Full-Risk for Behavioral Health, Managed Fee-for-Service for Physical Health: In Massachusetts, all non–dual- eligible and noninstitutionalized Medicaid beneficiaries are mandatorily enrolled in some form of managed care. Approximately 40 percent of managed care enrollees choose the State’s primary care case management program, known as the PCC Plan; the balance enroll in one of five MCOs. The State, through the Executive Office of Health and Human Services, contracts with a single vendor (currently a BHO) to manage behavioral health services on a capitated basis for PCC Plan enrollees and to administer the PCC Plan itself. Under a reprocurement of this contract released in May 2011, the State is looking to increase the contractor’s role in providing integrated care management for high-need, high-cost enrollees in the PCC Plan. As proposed, the contractor would be charged with increasing integration among providers of medical and behavioral health care, increasing integration of treatment for mental health and substance use disorders, and implementing a care management program to assist enrollees with complex medical and/or behavioral health needs in the coordination of their care. The contractor will be eligible to receive financial incentives tied to improved outcomes among enrollees. Conceivably, the future contractor could be a BHO with capacity for medical care management, or an MCO with capacity for full-risk management of behavioral health services.
Full-Risk for Behavioral Health, Fee-for-Service for Physical Health: The Iowa Plan is a statewide Medicaid BHO that provides behavioral health services to almost all Medicaid beneficiaries under age 65. Enrollment is mandatory, with more than 80 percent of Medicaid beneficiaries enrolled. Launched in 1999, the Iowa Plan is currently administered by Magellan under a contract with the Iowa Department of Human Services (DHS). The Medicaid capitation that DHS pays to Magellan includes 2.5 percent dedicated to a community reinvestment fund that finances initiatives to improve care management. Magellan and DHS use a request for proposal (RFP) process to fund promising initiatives.
The most recent RFP, issued in March 2011, sought proposals for “Integrated Health Homes” aimed at improving the coordination of behavioral and physical health services. DHS and Magellan selected four partnerships for the pilot, including three partnerships between community mental health centers and federally qualified health centers (FQHCs), and one between an FQHC and an organization providing Assertive Community Treatment to persons with SMI. Under this pilot, Magellan is at full risk for mental health services, while physical health services are funded by Medicaid FFS payments. Thus, while not achieving full system-level integration in its current form, this pilot could
serve as a stepping stone toward more complete integration in future iterations.
Considerations
Readiness and Capacity. BHO-based integration models may make the most sense for states with established BHOs, and thus with experience managing BHO contracts at the state level. As with integrating care through MCOs, states need to consider the capacity of potential contractors to manage the full array of physical and behavioral health services and to develop sufficient provider networks. BHOs typically are not at financial risk for prescription drugs (with the Arizona RBHAs as one exception) and thus may need to build capacity to manage pharmacy benefits (for example, in areas such as formulary development and pharmacy network management). However, it is worth noting that many BHOs have existing capabilities around clinical pharmacy management, particularly around the use of psychotropic medications (for example, data analysis, quality monitoring, consumer and provider-directed interventions to address polypharmacy, etc.).
External Support Needs. States looking to build this model around provider-level integration initiatives (such as health homes) need to address how the plans are expected to interface with, support, and oversee this broader set of coordination activities.
Special Considerations for Dual Eligible Individuals. States that wish to include dual eligible individuals in integrated BHO models may be well served by incorporating the requirement that the BHO also be a Medicare SNP. Given the high representation of dual eligible individuals among the SMI population, efforts to integrate physical and behavioral health care for individuals with SMI will likely fall short without full integration of acute care benefits (including prescription drugs) for Medicare beneficiaries.
Pros
- Integration of services creates alignment of financial incentives across physical and behavioral health systems.
- Full integration of administrative data for care management purposes is possible.
- Beneficiaries have seamless access to benefits and services.
- This option leverages specialty capacity of the behavioral health system to serve a population that it may know best, and where consumer engagement may be greatest.
- BHOs have core managed care capacity that can be leveraged across a broader array of benefits, namely information systems, quality management/utilization management functions, experience in building and managing provider networks, and communicating with beneficiaries.
Cons
- It may be difficult to identify/attract plans with sufficient capacity across both domains, as BHOs generally have very limited experience in providing physical health and prescription drug services.
- Questions regarding oversight authority may arise between Medicaid and mental health agency counterparts. An inclusive design process, engaging all relevant agencies and other stakeholders, can mitigate risk of contentious debates.
- There is limited experience to draw from, as these models are still emerging.
- Many Medicaid BHOs do not have experience with Medicare – a capacity that they would need to develop in order to serve dual eligible individuals effectively.
http://www.integratedcareresourcecenter.com/pdfs/ICRC_BH_Briefing_document_1006.pdf