States are experimenting with an array of strategies to address the fragmented delivery of services for Medicaid beneficiaries with behavioral health conditions. This report highlights the approaches adopted by four states--Illinois, Louisiana, Massachusetts, and Tennessee--to improve the coordination of physical health, behavioral health, housing, and other supportive services. It is not an exhaustive review of all state programs that are attempting to improve the coordination of services for this population. Previous reports have identified several other states and communities that are adopting innovative strategies (Greenberg 2012; Hamblin et al. 2011; Andrews et al. 2014). Rather, these case studies are intended to provide a snapshot of some of the significant features of selected state programs and identify some of the key successes and challenges associated with their strategies, as reported by state Medicaid officials, managed care representatives, providers, and consumers.
Although each state program has unique elements and was developed within the context of its existing service delivery system and political environment, we did observe some common features and perspectives, as detailed in this report and briefly summarized below.
A. Financing and Delivery System Reforms
The states are moving toward greater reliance on Medicaid managed care entities to coordinate care. Louisiana and Tennessee have expanded and integrated services at the health plan level. Louisiana is using a single MBHO, whereas Tennessee is contracting with three MCOs that are carving in behavioral health care. Both states require their managed care entities to provide care coordination services. In contrast, Illinois and Massachusetts have created funding mechanisms that reimburse in-person care coordination services at the provider level. In Massachusetts, the state Medicaid program reimburses CSPECH care coordination services as part of the MBHO's capitated rate. In Illinois, although the CCEs currently operate outside of managed care arrangements, the state hopes that they ultimately will market their services to the MCOs. In implementing these strategies, all four states have attempted to align service definitions and eligibility criteria with the goals of ongoing comprehensive coordinated care. They also have sought to ensure that changes in providing billing processes do not disrupt the delivery or payment of services; these efforts are continuing.
B. Partnerships and Care Coordination Mechanisms
State Medicaid programs recognize that the success of their strategies depends on the strength of provider buy-in and local partnerships, and have taken steps to foster local collaboration. Medicaid officials in Illinois and Massachusetts have positioned their initiatives within local community-based organizations that understand the needs of their communities and are familiar with local resources. Both the CCEs in Illinois and the CSPECH providers in Massachusetts deliver care coordination through local partnerships with various types of provider organizations. Likewise, the success of the initiatives in Tennessee and Louisiana are dependent on local provider networks' ability to identify and access community resources. Both of these states believe that the plan-level changes they have adopted will ultimately encourage local collaboration, including co-location of physical and behavioral health services. Regardless of the approach, stakeholders consistently reported that the smooth implementation of care coordination strategies requires strong communication among providers, MCOs, state agencies, and consumer organizations.
C. Care and Service Outcomes
Although some of these strategies are relatively new and continue to evolve, most of the Medicaid officials, managed care representatives, providers, and consumer representatives we interviewed were confident that these efforts have the potential to improve access to care and quality while reducing overall costs. Providers in all four states noted the value of data-sharing to drive quality improvement--although these state programs have very different capacities regarding data-sharing. Consumers and providers emphasized in-person care coordination and case management as essential to improve access to care. Future evaluation of these programs would be helpful in determining whether these specific components have furthered such outcomes.
D. Strengthening Linkages with Housing Services
All of these strategies recognize the need to bridge behavioral health services with housing supports and include steps that help foster relationships between behavioral health and housing providers and state agencies. In Illinois, the Medicaid agency encouraged the inclusion of housing providers as part of the CCEs. In Louisiana, by incorporating the PSH program into the state's single MBHO, new formal partnerships have emerged between state housing and behavioral health agencies, the managed care entity, behavioral health providers, and landlords and property managers. In Massachusetts, the MBHO has structured the CSPECH benefit flexibly enough to enable various housing and behavioral health provider partnerships. Finally, in Tennessee, behavioral health providers either own and operate a group home themselves or contract with local housing providers that own and operate the home and support services. These collaborations are particularly helpful in identifying limited housing resources, since Medicaid covers only physical and behavioral health services. The state strategies are also either encouraging or requiring Medicaid managed care plans and provider networks to develop and reimburse care coordination or case management strategies specifically focused on beneficiaries with housing needs.
E. Data Availability
Stakeholders stressed the importance of data-sharing in informing care coordination decisions at the provider level and identifying opportunities for quality improvement at the health plan and state levels. The availability of data and capacity of providers and other stakeholders to use these data for care coordination and quality improvement vary widely across programs. Some states, particularly those with managed care arrangements, such as Louisiana and Tennessee, have more robust data available to track service utilization and monitor quality. In other states, such as Illinois and Massachusetts, data-sharing between providers and other entities is more limited, due in part to the lack of common data platforms.
F. Future Research Opportunities
Although these states are monitoring their initiatives, none of them has conducted an independent, rigorous outcomes evaluation. Such research would be necessary to understand long-term outcomes and to identify specific mechanisms that facilitate or impede success.
The ability to conduct evaluations of these initiatives depends, in part, on the availability of high quality data. The availability of quantitative data varied widely across states. Some data were fairly consistently available, most notably data on the use of health and behavioral health services, such as those reported through Medicaid claims or managed care encounters. To some extent, housing data (such as housing status and use of supportive housing) were also available, particularly through states' HMIS. In contrast, the availability of data on physical and mental health functioning, consumer experiences with care, employment, and encounters with the criminal justice system varies. The initiatives in Tennessee and Massachusetts were implemented earlier and may have sufficient quantitative data to support an evaluation. In contrast, the initiatives in Louisiana and Illinois are relatively new and their future is uncertain. Further study of the implementation of these state initiatives could yield useful findings to inform the development of other efforts.