A. Background and Statement of the Problem
Medicaid beneficiaries with mental health and substance use disorders (SUDs) often have complex conditions that require a comprehensive array of physical, behavioral health, and other supportive services. Unfortunately, many of these beneficiaries fail to receive the necessary services and supports. For example, recent research has found that only 5 percent of Medicaid beneficiaries with schizophrenia or bipolar disorder maintain a continuous supply of guideline-concordant medications and receive medication monitoring, preventive physical health care, and outpatient mental health care during the course of a year (Brown et al. 2012). Individuals with serious mental illnesses (SMIs) in particular have high rates of emergency department (ED) use and inpatient hospitalizations, and have been found to be one of the costliest groups of Medicaid beneficiaries (Kronick et al. 2009; Durden et al. 2010; Greenberg 2012). Furthermore, this population is at risk for homelessness and housing instability, and has trouble accessing public benefits and social services, including income support, supportive housing, and employment programs (Perese 2007).
Historically, the financing and delivery of physical and behavioral health, and other supportive services, have been fragmented (New Freedom Commission 2003). Within Medicaid programs, physical and behavioral health services have often been provided through different financing arrangements, with inadequate coordination across managed care plans or providers. In many states and communities, housing supports and other human services are delivered through various agencies that do not coordinate with each other or with state Medicaid programs. Some states and communities, however, are taking steps to improve the coordination of care. The financing strategies to support these efforts range from enhanced primary care case management programs to the integration of physical health, behavioral health, and supportive service benefits within Medicaid managed care contracts.
Ongoing health care delivery system and payment reforms and demonstrations are providing states with opportunities to experiment with different models of care coordination. These include new and enhanced Medicaid options for home and community-based services, the development of health homes and Accountable Care Organizations, and dual-eligible demonstrations. These policy developments are taking place amid Medicaid eligibility expansions that are likely to increase the number of beneficiaries with mental health and SUDs in need of services. Within this rapidly changing system, policymakers and other stakeholder need information on the strategies that states are using to improve the coordination of care for Medicaid beneficiaries with behavioral health conditions. A better understanding of these strategies can help inform the efforts of other states and communities and also provide a foundation for more rigorous evaluations in the future. To be most beneficial, such research must take into account the perspectives of state officials, managed care representatives, providers, and consumers.
B. Purpose of This Report
In 2013, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) within the U.S. Department of Health and Human Services (HHS) contracted with Mathematica Policy Research to conduct case studies of the financing arrangements and delivery models that states are using to improve the coordination of care for Medicaid beneficiaries with mental health and SUDs in four states: Illinois, Louisiana, Massachusetts, and Tennessee. These case studies build on earlier research conducted by Mathematica (Andrews et al. 2014). This report profiles and describes the key elements of the strategy used in each state, including the financing mechanisms, state-level and local-level partnerships, use of data and information systems, and efforts to improve coordination with housing. Moreover, the case studies sought to describe the "on-the-ground" operation of the care coordination models from the perspectives of providers, consumers, and other stakeholders. Although these case studies do not evaluate the effectiveness or outcomes of the strategies used in these states, policymakers, managed care organizations (MCOs), providers, and other stakeholders may wish to consider the components of these strategies in their own efforts to improve care coordination.
Through document review, key informant interviews, and site visits, the case studies gathered information to answer five overarching questions:
To what extent does the strategy being implemented in each state involve changes in the financing, delivery, and scope of services available to adult Medicaid beneficiaries?
In what ways do these strategies seek to improve care coordination by fostering new partnerships and developing new care coordination mechanisms?
How do various stakeholders perceive these strategies as influencing the accessibility and quality of care, and health care utilization and costs?
How do these strategies provide or coordinate with housing and other social services?
What data are available in each state to potentially facilitate the monitoring of these efforts and future evaluations?
C. Roadmap to This Report
These case studies yielded a wealth of detailed information about the mechanisms being used to finance and deliver care in each state. This report attempts to concisely summarize the key findings. After briefly describing the data collection methods in the next chapter, Chapter III provides a short description of each state program (Appendices A-D provide detailed profiles of each program). Chapter IV synthesizes key findings across states in response to each research question. Chapter V concludes with a discussion of themes and similarities, and differences across states.