Strategies for Integrating and Coordinating Care for Behavioral Health Populations: Case Studies of Four States. B. State Context


Blueprint for Health is a major component of Vermont's health care reform strategy and has received much legislative support. Vermont initiated Blueprint as a chronic care initiative to curtail escalating health care costs. Policymakers learned that managing chronic diseases, such as diabetes and coronary artery disease, could help curb cost growth, and that the primary care setting was well positioned for delivering chronic disease management. Blueprint quality incentive payments and practice reforms were first codified in 2006 as part of Vermont's comprehensive health reform legislation (Vermont Act 191, An Act Relating to Health Care Affordability for Vermonters; Watkins 2012). As stated in the legislation, the goal of Blueprint was to "achieve a unified, comprehensive, statewide system of care that improves the lives of Vermonters with or at-risk for a chronic condition." The 2006 legislation required a pilot of early Blueprint activities, mainly related to diabetes care, which was first implemented in 2007 in three communities (HHS, AHRQ 2012).

Blueprint's focus expanded beyond chronic care management with legislation in 2007 (Vermont Act 71), and in 2008 more pilot testing was begun in the same three communities. These pilots included core Blueprint elements in place today, including PCMHs, CHTs, HIT, and financial contributions from Medicaid and major commercial insurers. The three pilot areas covered a population of approximately 60,000 patients, or about 10 percent of the state's 630,000 residents (HHS, AHRQ 2012; Watkins 2012).

In 2010, the state legislature (through Vermont Act 128) mandated statewide expansion of Blueprint reforms, requiring the state division responsible for implementation, the Department of Vermont Health Access (DVHA), to enroll all willing PCPs by October 2013 (HHS, AHRQ 2012). In addition to managing Blueprint, DVHA, within the Agency of Human Services, is designated as the state's Medicaid MCO and contributes funding as the Medicaid payer (Vermont Agency of Human Services 2011). (There are no behavioral health carve-outs under the MCO arrangement, although long-term care services are separately managed. Vermont's Medicaid MCO does not influence the structure of the Blueprint for Health, however, so is not discussed in this case study.)

State legislation in 2008 (Vermont Act 204) required all major commercial insurers in the state to contribute toward the Blueprint payment reforms (HHS, AHRQ 2012; Watkins 2012). Yet the state still had to obtain insurers' support. State administrators explained the potential cost savings of the Blueprint model and engaged insurers in further discussions to structure payment reforms. The small size of the state limits the number of private insurers, which helped Vermont to achieve support from all payers.

Multi-insurer involvement is one of the reasons Blueprint is considered a public-private partnership. Blueprint also receives input and support from other state agencies, private partners, and local participants; in some cases, partnerships are formal. State legislation established the Blueprint Executive Committee, which is composed of commissioners of DVHA, Department of Health, Department of Mental Health, and Department of Information and Innovation, as well as other government officials and non-governmental stakeholders (DVHA 2013a). There is also a Mental Health and Substance Abuse Advisory Committee, which includes leadership from the Department of Mental Health, the Department of Health's Alcohol and Drug Abuse Programs, and numerous treatment and advocacy organizations (DVHA 2012). In addition, a non-profit organization, Vermont Information Technology Leaders, has been involved in implementing the state's HIT infrastructure (DVHA 2013b). Since Blueprint is intended to be a comprehensive integration strategy at the community level that can be adapted to local needs and resources, local-level participants also influence Blueprint activities. Local participants include PCPs, community mental health clinics, human service agencies, housing agencies, area agencies on aging, and other local service providers. Various public and private stakeholders are also involved in the self-management workshops.

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