Summit speaker offers insights from field on combining physical, behavioral health care

Originally published by Crain’s Detroit Business

Crain’s 10th Health Care Leadership Summit debated integration of physical and mental health

Keynote speakers included Washington state Medicaid integration executive Isabel Jones and Michigan HHS Director Nick Lyon

By fall 2019, Michigan plans to go forward with three pilots and one demonstration project to test integration

With Michigan one year away from testing whether Medicaid HMOs can work effectively with behavioral health organizations to integrate health services in pilot programs, a Washington state Medicaid official Monday gave attendees at Crain’s Health Care Leadership Summit a glimpse of what the future may look like.

At The Henry Hotel in Dearborn, Isabel Jones, integration manager with the Washington State Health Care Authority, said three Medicaid health plans have already begun contracting in two of the state’s 39 counties to manage the physical and behavioral health of several thousand people. Results so far are promising, she said, with eight of 31 outcome measurements exceeding other counties and the remaining 23 outcomes showing no significant changes.

“The first (six months) were rocky for the health plans to implement (the plan and contract with all willing behavioral health providers in their markets), but we are happy with the results so far,” Jones said. Three more counties have begun integration this year with 180,000 lives covered with 24 counties joining in 2019 and the final 10 in 2020.

Jones said the Washington Legislature approved legislation in 2014 to move to an integrated Medicaid behavioral and physical health system by 2020, but counties could join earlier if they wanted. For nearly 20 years, Jones said, Washington Medicaid and others used three systems of care for physical, mental health and substance abuse services. The intellectual developmentally delayed population had already been integrated into managed care plans.

“We tried everything — memorandums of understanding, joint meetings (to improve care coordination) — to serve our clients better,” Jones said, adding that in 2016 the state of Washington ranked 46th nationally in providing mental health services to its population.

While Jones cited some evidence that outcomes have improved in the two counties, she said clinical integration between physical and behavioral health providers is still a work in progress.

“The Medicaid plans are trying to offer incentives to the providers to co-locate services under one location to make it easier to coordinate care and for (patients) to receive services,” she said. “There need to be mergers in the provider community or collaboratives to co-locate services.”

Lessons learned

As Michigan moves to design its integrated system, Jones said Washington found that mandating strict provider network adequacy standards for the HMOs is necessary. For example, Washington regulators require that any Medicaid HMO that contracts with the state must also contract with any willing behavioral health provider. She said if the state found out a provider in a market did not have a contract, the HMO would need to ensure that was corrected or explain why.

“When Medicaid enrollees are in the a single health plan, they can receive physical, mental and substance use services better because incentives are much better aligned,” Jones said. “The health plans can do early intervention and more to a higher level of care and deliver higher-end services.”

Jones said it appears that the Medicaid health plans are saving money on the physical health side by being able to deliver mild, moderate and serious mental health services. They appear to be using those premium dollar savings to expand behavioral health services, she said.

To prevent profiteering by the Medicaid HMOs, Jones said the state law limits the health plans to a 3 percent profit margin and they are required to spend at least 85 percent of premiums on medical care.

Another lesson Jones said Michigan should note based on Washington’s experience is that Medicaid HMOs have a totally different billing system than behavioral health providers.

“Focus on knowledge transfer. We spent a lot of time on communication” between the Medicaid health plans and the behavioral health organizations and providers, Jones said. “Health plans had to learn how the behavioral providers get paid. It is totally different. HMOs are not used to it,” she said.

But Jones said Medicaid health plans reached out to providers they never dealt with before and understand “whole person care” much better.

“HMOs learned to work with homeless shelters, the social (safety net) system and criminal justice, the jails. They are in constant collaboration,” she said.

One barrier that must be resolved over the next several years is developing an information technology system with shared medical records between HMOs and the behavioral health system, Jones said.

“Most behavioral health providers are migrating to new health records,” she said. “There is no integration yet. We have seen them move more with billing” and later she expects they will share clinical information once privacy issues are worked out.

Jones said Washington state received $1.5 billion from the federal government in a 1115 waiver that allowed integration and is using some of it to help providers with new IT systems.

Michigan integration

Earlier Monday, Nick Lyon, director of the Michigan Department of Health and Human Services, gave an opening keynote address to explain how Michigan began its integration process in early 2016 with the concept first proposed in Gov. Rick Snyder’s 2017 budget proposal.

Lyon said he saw the now well-known “Section 298 boilerplate” as a starting point to discuss how best to deliver and improve delivery of physical and behavioral health. He also said he saw it as a opportunity to find a way to direct more funds to behavioral health system.

But Lyon acknowledged what many in the Snyder administration discovered: the strength and passion of the advocates of mental health as they fought strongly against quickly turning over nearly $2.8 billion in funding to the Medicaid HMOs to manage.

“The boilerplate was not greeted” favorably by advocates of the current behavioral health system, especially those who rely on home- and community-based support services, Lyon said.

However, under the leadership of Lt. Gov. Brian Calley, the state health department began early in 2016 a Section 298 process that led to 45 meetings with 1,113 people from all sides. He said three pilots and one demonstration project will begin in October 2019 to test the best way to integrate care.

“Anything we can do to make the two systems work better will help” the more than 2 million people who use either Medicaid physical health or behavioral health services.

Read the full story at Crain’s Detroit Business