Best Practices and Barriers to Engaging People with Substance Use Disorders in Treatment. APPENDIX F: Deidentified Summaries of Health Plan Visits


Site Visit Debrief: SITE ID 2010

The Truven Health research team conducted a site visit with health plan ID 2010 on February 14, 2017. During the site visit, the research team met with the health plan's systems leaders, quality improvement team members, clinical leaders, and plan-affiliated case managers described in Table F.1.

TABLE F.1. Site Visit Interviewees for Health Plan ID 2010
Type of Interview Interviewees No. of People
Systems leader interview Health plan Medical Director
Executive Director of the SUD treatment clinic that is owned by the health plan
COO of the mental health treatment clinic that contracts with the health plan
Quality improvement team interview Health plan Medical Director
Executive Director of the SUD treatment clinic that is owned by the health plan
Clinical leader interview CEO and Medical Director of a major primary care clinic with shared ownership that contracts with the health plan
Medical Director of the community health center
Executive Director and provider from the women's health center that contracts with the health plan
Executive Director of the SUD treatment clinic that is owned by the health center
Case management interview Case Manager from the integrated primary care clinic that has shared ownership with the health plan
Case Manager from the women's health clinic that contracts with the health plan
Community Health Worker employed by health plan
Executive Director of the SUD treatment clinic that is owned by the health plan
Clinic tour Tour with clinic CEO and Medical Director of the integrated primary care clinic that has common ownership with health plan 2

A summary of key findings is included below.

Health Plan Description: The site visit was conducted with a Medicaid plan in the West. The plan operates under a coordinated care model and is managed by a local group of providers. Thus, the health plan primarily serves a smaller regional member population. The plan is focused on providing comprehensive, integrated primary and behavioral health care. It is owned by the partners of a local primary care clinic, who also own and operate a SUD outpatient clinic, and it is contracted with a local women's health center. A local mental health clinic also is considered a delegated entity of the plan. These close associations between physical and behavioral health providers promote integrated care for members of the plan.

The plan includes several committees that govern the plan actions. A quality and compliance committee meets weekly to review member needs and feedback and to discuss any pertinent governance issues arising within the plan. A clinical advisory panel includes plan leadership as well as leaders from health facilities within the community. The panel meets monthly to review changes within the health plan, changes within state Medicaid policy, and community needs. A citizen advisory committee also meets to provide the health plan with feedback on member needs.

Facilitators of IET: All interview groups described their co-located SUD and mental health treatment counselors as a key facilitator to their success with initiating and engaging beneficiaries in SUD services. These counselors are located in the commonly owned integrated primary care office. When providers are alerted a patient's risky substance use behavior or have a patient requesting SUD treatment, the providers are able to bring a counselor into the examination room for an immediate linkage to care. Individuals who do not want to engage in SUD services at an SUD clinic (whether because of stigma or other issues) are able to obtain office-based opioid treatment including buprenorphine and certain counseling services in the primary care office. This option has improved SUD treatment engagement in their beneficiary population.

System leaders and clinical providers also cited their universal SBIRT practices as a "distant second" to co-location but nonetheless a major facilitator to SUD treatment initiation. They described the utility of the SBIRT screening for identifying risky behavior, but highlighted the co-located counselors as the major facilitator of actual initiation.

Interviewees also identified the small and intimate community-setting in which the health plan and its affiliated providers are located and the ability to establish trust between patients and providers as key to engagement in treatment.

Barriers to IET: Major initiation and engagement barriers include waitlists for residential treatment services throughout the region, an inadequate number of inpatient facilities, and few DATA 2000-waivered physicians to prescribe buprenorphine.

Quality Improvement Methods: The plan relies on local governance to design quality improvement initiatives. A quality committee consisting of plan leadership regularly reviews members' needs as well as state Medicaid quality performance metric requirements. The health plan focuses resources on achieving benchmark improvements for the metrics they are financially at risk for by the state Medicaid agency. When the state included a metric for universal SBIRT for SUDs, the plan developed their embedded SUD counselor implementation strategy in their local primary care clinic.

The plan also is actively monitoring state and national trends in SUD treatment and identifying way to implement best practices locally for their population. Previous projects have included educational campaigns, specialized screenings for pregnant women, and the creation of a pregnancy resource specialist position to coordinate care for pregnant women with SUD.

Benefit Design: The health plan reimburses for all benefits included in the state Medicaid benefit array. Reimbursable SUD services include medically monitored and medically supervised detoxification programs, outpatient and IOP treatment, inpatient treatment, and residential treatment. The benefit array also includes MAT medications including methadone and buprenorphine, both of which require prior authorization. Beneficiaries also may receive naloxone free of charge under the plan benefit.

The health plan established an in-house quality committee that is able to approve reimbursement for additional services. Plan affiliated providers can bring individual beneficiary cases before this committee to lobby for a specific service to be covered if the service is outside of the typical benefit design.

Reimbursement: The health plan reimburses most providers under a capitation model. The state Medicaid agency sets rates based on population risk factors, age, and certain comorbidities. The plan representatives said this capitation model helps to reinforce their chronic care model of treatment. The health plan also is required to report on a set of quality health metrics determined by the state Medicaid agency. Universal SBIRT for SUDs is included in the state's quality metrics. The state Medicaid agency places a 4.25 percent withhold on the health plan's total capitated budget. The health plan is eligible to earn back the withhold by achieving its improvement benchmarks on the quality measures. A subcommittee within the health plan is tasked with determining how to use any withhold earnings that the plan receives each year.

The plan refers beneficiaries out-of-network for specialty services and generally reimburses those providers at the standard state Medicaid rate. Care managers and community health workers are salaried employees of the health plan.

Network Adequacy: Several of the health plan representatives expressed concerns over network adequacy for various SUD treatment services. There is a general shortage of local detoxification facilities and available beds in the region's residential treatment programs. The health plan recently decided to support the opening of a local facility that acts as a "sobering center" for individuals requiring a safe environment when the detoxification facilities are unavailable. The plan also is referring members to IOP services when residential treatment beds are unavailable. The plan began using telehealth to reduce the wait time members experience for psychiatry appointments. Additionally, the plan is concerned about the availability of DATA 2000-waivered prescribers in their local geographic region, so the plan is encouraging their affiliated physicians to become waivered.

Market and Beneficiary Characteristics: The health plan serves Medicaid beneficiaries in one designated region of the state, with its covered population being predominantly White and younger adults. Regarding SUDs, the plan has a growing prevalence of prescription opiate and heroin addicted members. However, methamphetamine use is still the most prevalent illicit drug in the region. The majority of members with an SUD also have a comorbid mental disorder.

Site Visit Debrief: SITE ID 2006

The Truven Health research team conducted a site visit with health plan ID 2006 on April 11, 2017. During the site visit, the research team met with the health plan's systems leaders, quality improvement team members, and clinical leaders described in Table F.2.

TABLE F.2. Site Visit Interviewees for Health Plan ID 2006
Type of Interview Interviewees No. of People
Systems leader Vice President of Operations and Execution for Corporate Behavioral Health 1
Quality improvement team Director of Quality and Compliance for Corporate
Behavioral Health Leader of Behavioral Health Team's HEDIS Domain Work group
Clinical leaders National Behavioral Health Medical Director
South Regional Medical Director
State Behavioral Health Medical Director

A summary of key findings is included below.

Health Plan Description: A site visit was conducted with a Medicaid plan located in a Southern state. The plan covers a significant part of the state, including many of the major cities. This local plan is part of a larger national health insurer group and thus is managed both locally and with substantial oversight from the corporate office. Behavioral health initiatives and decisions are initiated at the corporate level to ensure operational and clinical consistency across state plans. The local health plan quality teams are responsible for implementing behavioral health policies and procedures, ensuring compliance with state regulations, and developing initiatives of their own. Leaders of the plan expressed a commitment to having local behavioral health and physical health medical directors operate within their community while communicating closely with the national corporate office and Chief Medical Director.

Facilitators of IET: Clinical leaders acknowledged that health plan case managers play a substantive role in engaging members in care. One of their case managers who is an SUD specialist has joined the clinical staff in weekly rounds meetings, which has improved their ability to assess member risk and recovery progress. Systems leaders also believe that their discharge planning and coordinator program is successful in ensuring follow-up after hospitalization for SUD issues.

Barriers to IET: Clinical leaders acknowledged that a lack of screening for SUD by providers was a significant barrier to getting more people to initiate and engage in treatment. SBIRT currently is not well reimbursed in the state. To alleviate this, the local plan has undertaken its own pilot SBIRT initiative with one provider for children and adolescents, which will hopefully expand to adults and in other settings. Additionally, PCPs often do not engage in ongoing conversations about SUD risks with their patients, which is a barrier to patients engaging in care to make behavior changes.

Plan leaders and providers also acknowledged that the state Medicaid benefits for SUD are a major determinant for access to care. Reimbursement by the health plan is limited by the scope of Medicaid coverage within the state, which has not expanded Medicaid. The state's Medicaid program covers a limited population and does not reimburse for detoxification, residential care, IOP, or partial hospitalization, although it has limited exceptions for pregnant women.

Quality Improvement Methods: Like the overall governance structure, quality improvement decisions and initiatives are largely centralized at the corporate office then implemented by local operational and clinical leadership. The corporate office's government business division approves quality improvement initiatives and utilization management decisions and conducts annual member and provider satisfaction evaluations as well as state and HEDIS measure data analytics. Leaders of the health plan believe that centralized efforts are more efficient and they also view this centralized operation as a way to spread the use of best practices across local plans.

The health plan's Corporate Clinical Quality Management group supports the local plan's quality programs by writing annual quality templates for them to use and to build their local programs. Local quality leaders who report to the health plan medical director are accountable for plan-specific outcomes. However, the corporate behavioral health team also is responsible for HEDIS performance.

The corporate team is planning to launch an incentive program with a pay-for-performance arrangement for SUD providers in 2017. The team is developing a uniform program that will support this plan and metrics for evaluation will be developed. The local plan is involved in a state value-based purchasing initiative, which allows for both incentive and penalty payments.

Benefit Design: The health plan benefit array is identical to the state Medicaid benefit, which lacks a complete SUD care continuum. The state's current Medicaid program will only reimburse for detoxification and residential treatment services for pregnant women. As noted above, the plan coverage currently does not include IOP or partial hospitalization. The health plan employs an SUD specialized case manager to coordinate care for all members. Suboxone, methadone, and Narcan are covered without prior authorization. Vivitrol requires prior authorization.

Reimbursement: The health plan receives a per member per month rate and is required to spend at least 90 percent of this reimbursement on medical services and no more than 10 percent of it on administrative services. Provider reimbursement rates are defined in provider contracts. Changes such as enhancing services are met with requests for additional reimbursement from providers. Offering incentives or penalties or adding service requirements for providers runs into challenges because of reimbursement rates. All provider incentive programs are developed at the corporate level and local plans can implement them, but providers must accept them. The rate to out-of-network providers depends on the state. Single-case agreements are needed to cover each of the out-of-network providers who are not reimbursed at 100 percent because then there would be no incentive for them to come in-network.

Network Adequacy: Interviewees expressed frustration over a general shortage and underutilization of psychiatrists in SUD service delivery in addition to the inability to reimburse for detoxification and other services not covered by the state Medicaid program. The health plan also expressed frustration over how few local MAT providers were willing to take on Medicaid patients. The state health plan is not engaging in telehealth services that may assist with provider shortages.

The plan conducts annual geo-access assessments to identify gaps in care by ZIP Code. Overall, the plan has saturated the market by contracting with all available SUD providers. Nonetheless, more SUD providers are needed to meet plan needs.

Market and Beneficiary Characteristics: The health plan covers a large area in a diverse state with large urban areas and rural areas that differ greatly. The largest industries are tourism, agriculture, health care, and aerospace. The substances most commonly seen in treatment are alcohol, heroin, and crack cocaine. Young people also are presenting because of synthetic marijuana and bath salt use. Prescription opioid use is more limited as the state responded to the initial prescription problem earlier than many other states. Use of PDMPs and plan restrictions on pill quantity and number of prescriptions has curtailed prescription opioid analgesic use.

Site Visit Debrief: SITE ID 2003

The Truven Health research team conducted site visit interviews with health plan ID 2003 between April 27, 2017 and April 27, 2017. During the site visit, the research team met with the health plan's systems leaders, behavioral health team, and provider contracting and plan product development team described in Table F.3.

TABLE F.3. Site Visit Interviewees for Health Plan ID 2003
Type of Interview Interviewees No. of People
Systems leaders President of Public Plans
Chief Medical Officer of Public Plans
Vice President of Finance, Network and Business Performance of Public Plans
Vice President of Care Management of Public Plans
Vice President of Community Relations and Product Management for Public Plans
Behavioral health team Behavioral Health Medical Director for Public Plans
Director of Behavioral Health for Public Plans Manager of Integrated Care
Management for Public Plans
Provider contracting and plan product Director of Provider Contracting for Public Plans
Product Manager for Public Plans

A summary of key findings is included below.

Health Plan Description: This site visit was conducted with a Medicaid plan located in a New England state. This Medicaid managed care plan (MCO) plan is a part of a larger health plan enterprise consisting of three primary business lines including general commercial products, senior-focused products, and public plan products. The plan's Medicaid MCO falls under its public plan product line. As one of the state's six MCOs, this plan covers approximately 230,000 lives across all but one small region of the state.

The public plan's business line is governed by a public plans-specific leadership rather than overarching leadership at the enterprise level. The public plans business also has its own behavioral health and care management teams that provide services and direction for the Medicaid MCO.

Facilitators of IET: Interviewees attributed much of their success on the initiation and engagement in SUD treatment measures to the health plan's overall business philosophy. Interviewees described an overarching plan attitude that promotes respect for the plan's beneficiary membership and focuses on addressing the unmet needs of underserved populations. Systems leaders described their approach as taking the "long view" of SUD treatment that starts with identifying individual member needs and continuously providing appropriate supports over time to help them engage. Several interviewees highlighted examples of the health plan's providers reaching out to individual members to address their specific unmet housing-related needs and to provide them with motivation to engage in SUD treatment services.

Recently the state Medicaid authority changed the way beneficiaries affiliate with MCOs. Instead of being able to change MCOs whenever they want, Medicaid beneficiaries now are locked into receiving coverage from one MCO for a full 12 months. This new policy change is viewed as a facilitating mechanism for ensuring care managers can follow-up and monitor the ongoing and long-term treatment needs of the covered population. It also addresses a treatment barrier whereby beneficiaries would be "locked-out" of receipt of opioid prescriptions and would simply change to a plan with which they had no history.

Many of the identified facilitators for beneficiary initiation and engagement in SUD treatment are quality improvement programs that were developed after 2014, the year for which we monitored their performance measures. These additional initiatives are discussed below under "quality improvement."

Barriers to IET: Interviewees considered their delay in learning about member admissions the biggest challenge to engaging them effectively in subsequent SUD care. No prior authorization is required when members enter a detoxification facility; therefore, the plan generally does not learn of the clinical episode until the member is discharged or later. Behavioral health team members said that, even when they phone detoxification facilities to inquire about their members, the facility's staff are unwilling to provide any information. Interviewees said that many acute treatment facilities interpret state and federal health care privacy laws differently and use these laws to avoid engaging with the health plan care managers.

Interviewees also expressed challenges in identifying SUD inpatient and residential facilities that would accept pregnant women. The interviewees reported that providers are uncomfortable treating pregnant women, especially those on MAT. The plan does not engage its providers in any quality improvement or SUD education-focused initiatives because these providers would be overwhelmed. Many of the health plan's contracted providers have large patient volumes and are contracted to provide services to Medicaid beneficiaries under the other five MCOs. Thus, it does not seem possible to ask providers to undertake any new SUD-focused initiatives.

Homelessness is another major barrier to engaging members in treatment. The lack of a stable address serves as a barrier to care managers conducting outreach with these members following hospital admissions.

A general lack of step-down treatment also was identified as a major barrier to keeping members engaged in care after detoxification services. Although the interviewees felt there is sufficient access to acute treatment, they identified residential treatment and MAT prescribers as major treatment gaps.

Quality Improvement Methods: Since 2014, the year of our data on HEDIS IET measures, the health plan has developed more programmatic ways to encourage initiation and engagement in care. The health plan has focused on hiring more experienced care management staff and on establishing a formal quality improvement process that actively assesses member needs. Through this process, the plan has developed several initiatives described below.

The health plan employs an SUD navigator whose job it is to serve as a resource to any member with an SUD as well as any family members needing support to ensure they are familiar with their benefits and are aware of which SUD treatment programs are in their area. The health plan also employs master's level behavioral health care managers, medical care managers, and clinical community specialists who will outreach to members in the hospital or in the community. Care managers monitor member admissions and aim to conduct a face-to-face visit with the member before he or she is discharged. Their goal is to serve as a point of continuity as the member graduates through the continuum of SUD care. Interviewees noted that they were unaware of any other Medicaid MCO in the state that provides this predischarge service to its members. Additionally, the health plan employs utilization management staff who not only review service initiation but also monitor member treatment plans to ensure members are accessing services they need.

Weekly meetings bring together the health plan's senior leadership, physicians, care managers, and SUD navigator to discuss individual high-need members. These meetings are used to identify individual cases where the health plan may provide additional support beyond what currently is reimbursed under Medicaid. For example, interviewees described how the plan's resources were used to provide the support one member needed to regain custody of her newborn following her successful completion of an SUD treatment program.

The health plan also recently began encouraging members to use a smartphone application that allows users to have instant access to support groups and online case management services.

Benefit Design: The health plan benefits are dictated by and match those outlined in the state Medicaid authorities' list of covered services. Covered services include detoxification, inpatient, outpatient, IOP, and partial hospitalization services as well as a day treatment program for pregnant mothers. MAT also is a covered benefit for all alcohol-related and opioid-related medications including methadone, buprenorphine/Suboxone, Vivitrol, and acamprosate. Although naloxone is a plan benefit, members must pay a co-pay to receive this medication. Crisis services are provided through the state emergency services program. Any Medicaid beneficiary in the state needing crisis services is guaranteed a full evaluation within 1 hour of request, either in a hospital or community location.

The plan is not using telehealth services to meet its members' SUD needs. Per the plan, the provider community has not been receptive to telehealth technology because they would be paid less than if they just had the client come in for an in-person visit. The plan believes that even rural beneficiaries live within 90 minutes of a behavioral health provider, so geographic access is not a significant barrier in receiving services.

Reimbursement: Contracted providers operate under a fee-for-service payment model. Both in-network and out-of-network providers are reimbursed at generally the same rates as outlined by the state Medicaid authority. The plan will, on a case-by-case basis, contract certain providers for enhanced rates when those providers are deemed to offer a substantive benefit to the health plan. For example, the plan may reimburse providers at 105 percent of the standard state Medicaid rate if those providers are serving an area with low network adequacy or if the providers have become known as "the provider to see" for quality services. The health plan must submit a special request to the state Medicaid authority to contract providers for rates above 105 percent, so such arrangements are not frequently made.

Network Adequacy: The health plan is required by the state to conduct geo-access assessments identifying gaps in care as well as time and distance to providers. The plan is meeting all of its NCQA standards for access. However, interviewees suggested that the defined access standards differ from what their actual member population needs. For example, although the state has contracted with all the existing providers in one of its more rural areas and meets access requirements, the interviewees still felt there are not a sufficient number of providers in this area to meet all the plan's member needs. Interviewees also felt that there is a dearth of step-down services available once members are discharged from detoxification facilities.

Market and Beneficiary Characteristics: This health plan serves Medicaid beneficiaries in all but one small region of the state. The state is geographically diverse with both large urban and rural areas. The largest industries are health care and institutions of higher education. The substance uses that are most commonly seen in treatment are alcohol, heroin, fentanyl, and prescription opioids. The state has made addressing the opioid epidemic a priority issue and has significant legislative support for new and ongoing initiatives related to expanding access to SUD treatment and prevention. First responders including police departments also are highly involved in facilitating access to SUD treatment. However, the interviewees described community stigma as a major hurdle for disseminating SUD prevention and treatment education, but they indicated that it seems to be more pronounced in the affluent, non-Medicaid populations than in the Medicaid population served by this plan.

Site Visit Debrief: SITE ID 9522

The Truven Health research team conducted virtual site visit interviews with health plan ID 9522 on 05/09/2017. During the site visit, the research team met with the health plan's systems leaders, behavioral health team, and quality improvement team staff described in Table F.4.

TABLE F.4. Site Visit Interviewees for Health Plan ID 9522
Type of Interview Interviewees No. of People
Systems leaders Behavioral Health Medical Director
Director of Plan Operations
Behavioral health team Manager of Behavioral Health Services 1
Quality improvement team Director of Quality 1

A summary of key findings is included below.

Health Plan Description: This site visit was conducted with a Medicaid plan located in the Midwest. This Medicaid MCO plan operates under a regional name but is a part of a larger health plan enterprise. Much of the regional plan's directions and initiatives are provided or developed at the local level rather than by the corporate office. The behavioral health team reports directly to the local plan's Medical Director and indirectly to the corporate leadership. Corporate leadership acts mostly as a consultant to support the regional plan with quality improvement or behavioral health-related initiatives.

This MCO is one of several serving the state Medicaid population and thus has substantial market competition. However, it represents one of the smaller MCOs with approximately 65,000 covered lives largely concentrated in the state's more urban areas.

Facilitators of IET: Co-location of the regional plan's three case management teams--SUD, physical health, and utilization management--was cited as one of the plan's major facilitators for effectively coordinating services and keeping members engaged in care. All three teams are housed locally and engage in biweekly meetings to discuss members who may need support from one or more of the teams. The behavioral health and utilization management teams also meet regularly to review inpatient cases and plan for discharge. The behavioral health case management team conducts biweekly internal meetings to discuss hard-to-reach members or challenging cases with the Behavioral Health Medical Director. Case managers actively engage in face-to-face meetings with members in the community to identify their needs and follow-up on reasons for missed appointments. Case managers have developed positive relationships with several emergency rooms, which have resulted in emergency room staff reaching out and alerting the health plan that its members are receiving treatment and facilitating in-person meetings in the hospital.

The health plan also compiles provider score cards to monitor PCP performance and access. When physicians are identified as not promoting sufficient access (e.g., restricted office hours, delayed appointments), the health plan conducts private, individual meetings to clarify contract requirements.

Barriers to IET: Competing demands for both physical health and basic necessities, such as housing and transportation, serve as major barriers to engaging in treatment. Although the health plan can provide transportation services to its members, the state does not allow Medicaid members to bring their children in the vehicle. This prevents many parents from engaging in services when they cannot secure day care services. Additionally, poor network adequacy for MAT is viewed as a major barrier to ensuring access to care for members. The health plan is actively reaching out to identify new prescribers or prescribers accepting new patients, but statewide access remains problematic.

Quality Improvement Methods: The health plan actively monitors all members who are admitted for inpatient treatment. They compile an inpatient census list to discuss these cases during case management meetings and to conduct member benchmarking. The plan is using an electronic case management system that allows the behavioral health team to monitor individual patient needs including physical health status and to identify ways to improve care coordination and encourage engagement in treatment. The behavioral health case management and utilization management teams also meet regularly to discuss treatment and discharge plans, ensuring patients receive services to meet all their clinical and recovery support needs.

Benefit Design: Health plan benefits largely mirror the state Medicaid benefit array. The state Medicaid authority does not permit reimbursement for residential treatment programs, so the health plan must refer its members to the county for those services. The plan does provide coverage for other SUD services including outpatient, inpatient, and partial hospitalization services; MAT; and transportation to clinical services. However, prior authorization is required for IOP and partial hospitalization services. The state Medicaid authority permits reimbursement for peer support services for the SSI population, although the health plan currently is not providing these services to its members.

Reimbursement: The health plan is paid a capitated rate for its member population. The state Medicaid authority takes a withhold of 2.5 percent (approximately $3.5-$4 million), giving the plan the opportunity to earn the full rate back on the basis of their performance across 12-14 quality measures; four of these measures are related to SUD, including tobacco. The plan is eligible to earns its full withhold if it meets the high-performance goal and 50 percent if it meets the medium performance-goal, but it earns 0 percent for lower performance. The plan also can earn part of the withhold for improvement rather than just attainment. The plan does not have a set shared savings plan to allocate earnings. Instead it focuses its resources on addressing the measure or performance service area where it performed the poorest.

In-network and out-of-network providers are reimbursed at the state Medicaid rates. In case-by-case situations, the health plan may decide to reimburse providers at an enhanced rate depending on the out-of-network need. An alternative payment methodology, determined by the state, is applied to providers working in low-capacity areas.

Network Adequacy: The state Medicaid authority requires that the MCO achieve network adequacy standards for time and distance to providers. The health plan is having difficulty achieving network adequacy in the state's more rural counties. Generally, there is a shortage of outpatient detoxification providers that results in the health plan's referring its members to inpatient detoxification services. There also is a dearth of buprenorphine prescribers in the state, which poses network adequacy challenges. On a quarterly basis, the behavioral health and provider relations team reach out to all DATA 2000-licensed providers in the state to determine if they can accept new patients. Most prescribers are not accepting new patients. The plan currently is not using telehealth to augment its network access but is actively looking into expanding into this capability.

Market and Beneficiary Characteristics: The health plan serves a predominately urban and suburban Medicaid population. Several interviewees highlighted socioeconomic challenges of the plan's covered population including transportation needs and homelessness. Drug use in the coverage area mirrors national trends, with high rates of OUDs as well as a steady rate of alcohol use disorders. Interviewees were unable to say whether there was more prescription opioid or heroin use, but indicated that both are present.

Site Visit Debrief: SITE ID 8200

The Truven Health research team conducted site visit interviews with health plan ID 8200 on June 1, 2017. The research team interviewed the health plan's systems leaders, a key leader for behavioral health initiatives, the plan's quality improvement team, and core leaders in case management.

TABLE F.5. Site Visit Interviewees for Health Plan ID 8200
Type of Interview Interviewees No. of People
Systems leaders Assistant Director of Regional Mental Health and Chief of the Department of Psychiatry
Chief of Addiction Medicine
Behavioral health leader Chief of Addiction Medicine 1
Quality improvement leaders Program Director
Medical Group Physician
Managerial Consultant for Quality and Operations Support
Case management leaders Licensed Psychologist (2)
Marriage and Family Therapist

A summary of key findings is included below.

Health Plan Description: This site visit was conducted with a commercial plan located in the West. This health plan functions as an integrated model, providing both health insurer and medical group services to its covered lives. Thus, the plan is a very physician-led one. This large national plan is organized into distinct regions, each with local oversight and decision-making power for behavioral health and quality improvement initiatives. This federated model enables the plan to adapt to its local population needs.

Facilitators of IET: The health plan implemented universal SUD risk screening in primary care settings, which has enabled it to provide more early intervention services and facilitated initiation in SUD treatment as well. SBIRT prompts were embedded in the plan's electronic medical record to improve use. The health plan also has identified physician champions in each of its medical centers to encourage other providers to screen and refer patients to local addictions and recovery clinics operated by the health plan.

However, the plan did find that providers were overdiagnosing patients, which inappropriately inflated the number of beneficiaries who needed to be engaged in services. The plan created new internal codes that allowed physicians to mark patients as engaging in risky use without designating them as having a diagnosed SUD. Reducing the number of inappropriately diagnosed beneficiaries helped the plan to target resources and improve on the engagement measure.

Each medical practice under the health plan generates a daily "Best Practice Alert" report for each physician in the practice. This report contains a list of all patients with SUD diagnoses and a note indicating whether the patient is in treatment, has a referral, or still needs a follow-up from the physician regarding a referral or change of diagnosis. The physician champion uses this list to create a fall-out list of all patients who need follow-up services. The champion then meets with these patients' providers to remind them of the follow-up and other clinical requirements. The health plan also generates provider report cards that rank each physician's performance in providing follow-up services against the performance of other physicians in the medical group.

Immediate access to services was identified as another facilitator of treatment initiation and engagement. Because of the integrated model and service requirements set by the insurer, salaried providers are unable to place any beneficiaries on a waitlist for services. All beneficiaries requesting SUD treatment services must be seen within 2 days. Approximately 25 percent of beneficiaries receive same-day services.

Barriers to IET: Physicians cited lack of new SUD treatment providers joining the field as a major barrier. They are worried that network adequacy is not sufficient to meet beneficiaries' growing demands, especially in rural areas. They are seeing a major shortage of psychiatrists in their network. Sufficient access to residential treatment beds also are a concern for the plan. The plan provides partial hospitalization and outpatient services through its own medical groups, but must contract with external facilities to provide residential care. Additionally, several providers cited members' stigma about SUD diagnoses as major barriers to engaging in care.

Quality Improvement Methods: The health plan's medical group oversees all quality improvement activities around the HEDIS measures and other SUD treatment initiatives. The plan enables physician practice leaders to implement initiatives specific to their local population needs. The plan has a health services research team and contracted consultants to help identify implementation strategies promoting evidence-based practices. The health plan generally prefers to pilot implementation strategies in one of its practice settings before rolling the strategy out across its entire covered region.

The plan also cited the ability to mine its internal database to identify missed follow-up appointments and other beneficiary trends in service utilization. These trends are then acted upon with interventions designed and implemented by the local physician practice.

Benefit Design: All pharmacy, behavioral health, and SUD treatment benefits are organized by the health plan. There are no prior authorizations for any SUD treatment services. The plan does not have any specified medical necessity criteria for service provision, so all services are available to plan beneficiaries.

The plan delivers SUD treatment services through community addiction and recovery programs that may be organized as any of the following: partial hospitalization, IOP, and outpatient providers. Residential services are contracted with community facilities and provided for 60 days. MAT is available to all plan members. The plan directly provides buprenorphine and naltrexone (oral and injectable) in its community addictions and recovery programs. However, methadone services are provided through contracts with external providers. It was decided that the plan would not dispense methadone directly because of the federal requirements associated with clinic infrastructure. Beneficiaries at risk for overdose can receive two units of naloxone so that they and a family member may carry the medication.

Reimbursement: The health plan operates as a membership organization with a per member per month capitated rate designated for each region. Although providers are affiliated with physician groups, they are contracted as salaried employees of the health plan. Because of its highly integrated model and extensive benefit array, the health plan has little need to contract with out-of-network providers. If the plan does contract with out-of-network providers, it generally reimburse these providers at the state Medicaid rate.

Network Adequacy: Interviewees felt that the health plan currently is meeting the network adequacy needs of its covered population. The state where the plan operates sets maximum mileage and travel time requirements for accessing care, which currently are being met. Additionally, the health plan has internal requirements to provide 2-day access for urgent care and 14-day access for non-urgent care services. Interviewees said that the plan currently is meeting those requirements, and a substantial portion of urgent care members are seen on the same day as their request.

However, there were worries that the SUD treatment workforce is not growing as quickly as the population's needs. Although the plan is using a substantial amount of telehealth services, its primary impetus was to provide members with more appointment flexibility rather than to solve access issues. Providers can conduct follow-up and brief consultation visits with members via secure video connections. However, the plan is not pushing for more use of these services to increase access in rural areas.

Market and Beneficiary Characteristics: The health plan is the largest HMO in the state and thus serves a geographically and demographically diverse population. The plan region is vast and includes several local medical centers with different provider groups in rural and urban areas. Most plan beneficiaries are employed and the plan contracts as the medical insurer to several city and state government agencies.

Site Visit Debrief: SITE ID 4019

The Truven Health research team conducted site visit interviews with health plan ID 4019 on June 5-6, 2017. As described in Table F.6, the research team interviewed the health plan's systems leaders, a key leader for behavioral health initiatives, the plan's quality improvement team and core leaders in case management.

TABLE F.6. Site Visit Interviewees for Health Plan ID 4019
Type of Interview Interviewees No. of People
Systems leaders Plan Presidents (2)
Senior Vice President of Operations
Behavioral health leader Chief Medical Officer
Medical Director of Behavioral Health
Director of Clinical Operations
Quality improvement leaders Director of Population Health Strategies
Vice President of Quality Improvement
Corporate Director of Quality and Performance Improvement
Senior Manager of Quality Improvement
Senior Manager of Quality Improvement Strategy
Network adequacy leaders Director of Network Development
Manager of Network Development for Behavioral Health
Provider Network Development--Behavioral Health Team Lead
Senior Vice President of Utilization Management
Director of Behavioral Health Utilization Management
Care coordination leaders Senior Director of Care Coordination
Senior Managers of Care Coordination (2)
Manager of Behavioral Health and Care Coordination
Manager of Care Coordination
Director of Community Care Coordination
Behavioral Health Community Care Coordinator Team Leads (2)

A summary of key findings is included below.

Health Plan Description: This site visit was conducted with a Medicaid managed care plan located in the Midwest. The plan operates with local state leadership and corporate leadership based out of a neighboring state. The plan has several state Medicaid plans, which prompted them to adopt a philosophy of managed care operationalized by local plan leaders that communicate with the local providers and beneficiaries. Behavioral health care coordination is organized both locally and centrally by the corporate office. The national plan can centrally locate some of its behavioral health efforts (e.g., phone outreach for care coordination) but largely values a "boots on the ground" approach by local providers.

Facilitators of IET: The health plan actively analyzes its internal pharmacy data to identify beneficiaries who exhibit indicators of undiagnosed behavioral health care needs. The corporate office generates a monthly report identifying any members that fill three or more narcotic prescriptions at three or more pharmacies that are written by three or more prescribers. The members identified in this report are reviewed for potential member safety concerns. In addition, cases are reviewed if care coordination services are being provided or if a care coordination referral is appropriate for these individuals.

The plan also uses its EHR data to identify when members are admitted for a SUD diagnosis. Behavioral health coordinators can reach out as soon as they get the notification from the facility. Plan-contracted providers also may use their provider portal to refer a member for care coordination services with one click. The health plan care coordination team is notified instantly and conducts outreach to the member.

Care coordinators pointed to the plan's focus on identifying community support services where the members live as a major facilitator to treatment engagement. Because members often will not engage in care that is not provided in their local neighborhoods, finding the right resources nearby is critical to the plan's approach. Plan providers also believe that developing trusting relationships between members and the care coordination team through face-to-face outreach and regular phone calls is critical to successfully engaging members in care. Members might not be ready for treatment at the first outreach, but the care coordination team will persist and regularly follow-up to conduct motivational interviewing that promotes treatment engagement.

Barriers to IET: The health plan identified the timeliness of service use notifications as a major barrier to being able to provide immediate outreach to their members. Such notifications of outpatient service utilization often occur after the 14-day follow-up period, which reduces the plan's ability to conduct outreach and engage the member in care. There has been substantial improvement with this delay, but the issue remains a work in progress. This is of particular concern when members enter detoxification facilities or other facilities familiar with 42 CFR Part II. Staff at inpatient SUD treatment and detoxification facilities often tell the plan's care coordinators that they will not share records or provide notifications of members' admissions because of 42 CFR Part II restrictions. One plan representative indicated that non-specialized facilities are more likely to reach out because they are less familiar with 42 CFR and tend to follow the Health Insurance Portability and Accountability Act (HIPAA) requirement that allows them to communicate with the payer. When asked, the plan representative indicated that the recent changes to 42 CFR do not change matters for health plans and do not improve their ability to coordinate care for members.

Interviewees identified the state's transition from siloed behavioral health services to embracing Medicaid managed care as a major barrier to providers truly understanding how the health plan can help care for their population. They cited provider knowledge of managed care, care coordination, and other outreach services as barriers they are actively addressing with educational efforts and trainings.

Finding accurate contact information for beneficiaries is another barrier to engaging them in care. Many members become unreachable because they frequently change their phone number or address. General stigma around SUDs and members not wanting to be associated with that diagnosis is another barrier to engaging them in care, particularly in standalone facilities.

Quality Improvement Methods: The health plan actively works with subject matter experts and takes advantage of SAMHSA and American Psychiatric Association educational webinars to stay current on evidence-based practices. The health plan has started to approach quality improvement from a population health perspective. It is using the Johns Hopkins ACG® System to stratify and segment its covered lives from the healthiest to the sickest members on the basis of their illness burden. From there, the health plan is able to allocate members to receive specific clinical interventions based on needs. This approach is helping the plan identify the health needs of their moderate-risk or moderately unhealthy members and target them before their risks increase.

Benefit Design: The health plan benefit design is matched to that of the state Medicaid benefit array. Because prior authorization often causes barriers to accessing necessary services, all MATs are provided as covered benefits and do not require prior authorization. Naloxone also is covered under the plan benefit. Peer support services are not included as a state Medicaid benefit and therefore are not offered by the plan. The plan also is not providing telehealth services for any behavioral health care at this time. According to the interviewees, no providers have requested to use these services in rural areas, and the plan is concerned about the privacy requirements and costs associated with providing telehealth.

Reimbursement: The plan receives a capitated per member per month rate and a performance-based withhold dependent on its HEDIS and CAHPS performance. The IET measure is considered a bundled measure in the state, so this Medicaid plan must perform well on both the initiation and engagement aspects of the measure to receive its withhold payout. The measure also is bundled with all other HEDIS measures, and the plan must meet all benchmarks in order to receive the withhold.

Providers are paid fee for service. The health plan reimburses providers at 100 percent of the state Medicaid rate. The plan generally does not contract with out-of-network providers; however, if needed, the plan will use the state Medicaid rate as the baseline negotiation. The state is piloting a value-based payment arrangement with community mental health centers, but the arrangement is not specific to SUD treatment services.

The state budget crisis is having a significant impact on the health plan's ability to reimburse providers. The state owes a substantial sum of back Medicaid reimbursements to the plan, which in turn owes reimbursements to its provider network. Many Medicaid-only providers are unable to stay in business and several have stopped seeing Medicaid patients. The state has also kept the Medicaid reimbursement rate in flux, raising and lowering the rate, because of its budget crisis.

Network Adequacy: Interviewees reported that there are concerns about a shortage of psychiatrists and addiction-certified providers coming into the field to replace the retiring professionals. Executive leadership does not identify a shortage of MAT prescribers, but care coordinators report having a difficult time identifying prescribers willing to accept new patients, particularly in rural areas. SUD treatment services for adolescents and pregnant mothers also are scarce throughout the state. Most of the services targeting special populations are located in urban areas.

Market and Beneficiary Characteristics: The health plan serves Medicaid beneficiaries residing in all regions of the state. Despite growing use of prescription opioid and heroin, alcohol remains the most prevalent substance of misuse and abuse for the plan's membership. Cocaine also is commonly used among the plan's SUD population. Many of these individuals also have co-occurring physical health or mental disorders including schizophrenia.