HINDSIGHT, FORESIGHT, & INSIGHT:
State Financing Innovations to Integrate Physical and Behavioral
Health
October 5, 2011
Tricia McGinnis
Center for Health Care Strategies
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Integration = Opportunity to Improve Care/Reduce $$
► Top 5% highest-cost beneficiaries account for 57% of $$
► Among the most expensive 1% Medicaid beneficiaries (acute care only) 80% have 3 or more chronic conditions
► 49% of those with disabilities also have psychiatric illness► The presence of psychiatric illness increases spending and
hospitalization rates by as much as 75%
Yet, most are in fragmented and disconnected physical & behavioral health delivery systems
*Sources: RG Kronick et al., “The Faces of Medicaid III: Refining the Portrait of People with Multiple Chronic Conditions.” Center for Health Care Strategies, October 2009; C. Boyd, et al. “Clarifying Multimorbidity for Medicaid Programs to Improve Targeting and Delivery of Clinical Services.” Center for Health Care Strategies, December 2010.
Cost Impact of BH Comorbidity Among U.S. Medicaid-Only Beneficiaries with Disabilities
3SOURCE: C. Boyd et al. Faces of Medicaid: Clarifying Multimorbidity Patterns to Improve Targeting and Delivery of Clinical Services. Center for Health Care Strategies, December 2010.
What Ideal Care CAN Look Like:
WITHOUT INTEGRATED CARE INTEGRATED CAREx Multiple physical and behavioral health
providers who rarely communicate Coordinated care team of providers
x Beneficiary confusion regarding how to access the care they need
Dedicated care manager role to help patient navigation
x No centralized information sharing across providers
Real-time, comprehensive data available across all providers
x Health care decisions uncoordinated and not made from the patient-centered perspective
Health care decisions based on the individual’s needs and preferences
x Serious risk for emergency room use, hospitalization, and/or institutionalization
Dedicated commitment across providers to reduce emergency room use and repeat hospitalizations
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Complex Care Management: Critical Elements
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Innovations in Integrated Physical and Behavioral Health FinancingStates are exploring a range of options for integrating the management and financing of physical and behavioral health services with a focus on individuals with serious behavioral health needs.
Two innovations include:
1.Behavioral Health Organization (BHO) as Integrated Care Entity
2.Accountable Care Organizations (ACO) as Integrated Care Entity
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BHO as Integrated Care Entity
• Contract with BHOs to provide both physical and behavioral health services for individuals with serious mental illness (SMI) or other serious BH needs.
► Considerations Established BHO infrastructure is critical
Capacity of contractors to manage PH and BH needs
Adequate provider network
Whether to allow subcontracting
Incorporation into broader health home initiatives
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BHO as Integrated Care Entity
PROS► PH/BH system alignment of
financial incentives► Full integration of
administrative data► Leverages specialty capacity
of BH system for complex need population
► Potential for greater consumer engagement
CONS► Lack of BHO capacity in
providing PH and Rx services► Emerging model, thus limited
experience► Questions regarding oversight
authority
Innovations in Arizona
• RFI for specialty Regional Behavioral Health Authorities (RBHAs)
• RBHA would be full risk for and manage all behavioral health and physical health services for SMI beneficiaries
• Will operate under Department of Behavioral Health Services
• Closely connected to health homes
• MA-SNP capabilities
• No subcontracting
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Innovations in Massachusetts
• Based on PCCM program, which is one of several managed care options
• BHO at full risk for behavioral health and managed fee-for-service for physical health
• Financial incentives for improved outcomes
• BHO required to provide high-risk members:► Care management program to coordinate care► Integration of physical and behavioral health care providers► Integration of mental health and substance abuse treatment
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ACOs as Integrated Care Entities
• Regionally-based provider entities charged to provide both physical and behavioral health services for all individuals, including those with SMI
► Considerations Financial incentives through shared savings are key
Must have capacity to facilitate data sharing among providers
Requires strong behavioral health lead within ACO
Adequate primary care reimbursement is critical
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ACOs as Integrated Care Entity
PROS► Shared savings aligns
incentives and promotes coordinated care
► ACOs can function within managed care, PCCM, or FFS systems
► Potential for true clinical integration
► Potential for patient and community engagement
CONS► Significant start-up costs► Shared savings and
information exchange may be hindered by BH carve out environment
► Statewide implementation may be difficult
► ACOs will likely need to partner with multiple MCOs
ACOs in Minnesota
• Includes behavioral and physical health services delivered to non-dually eligible beneficiaries in FFS and managed care
• Deploys two shared savings models to attract integrated and non-integrated providers
• RFP emphasizes:► Comprehensive care coordination► Meaningful engagement of patients and families► Partnerships with community organizations, social service
agencies, and counties
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Parting Thoughts
• Integrated financial/management systems are critical to effective integration of health services
• States are undertaking a range of approaches to solve this disconnect
• Systems-level integration efforts must be paired with efforts to integrate services at the point of care
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Questions?
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State Technical Assistance
►The Integrated Care Resource Center was recently established by CMS to help states develop and implement integrated care models for Medicaid beneficiaries with high-cost, chronic needs
►Technical assistance (TA) to help states integrate care for: (1) individuals who are dually eligible for Medicare and Medicaid; and (2) high-need, high-cost Medicaid populations via the Health Homes state plan option as well as other emerging models
►Individual and group TA coordinated by Mathematica Policy Research and CHCS
►Visit www.integratedcareresourcecenter.org to submit a TA request and/or download useful resources, including policy briefs, tools, state best practice resources, and the latest CMS guidance
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