Strategies for Integrating and Coordinating Care for Behavioral Health Populations: Case Studies of Four States. I. Introduction

01/01/2014

Individuals with serious mental illnesses (SMI) and other chronic behavioral health conditions require a comprehensive array of physical, behavioral, and other supportive services in order to live independently in the community. Recent research suggests that less than 5 percent of Medicaid beneficiaries with schizophrenia or bipolar disorder receive regular medications, medication monitoring, psychosocial services, and any preventive physical health care during the year (Brown et al. 2012). Many of these individuals suffer from chronic physical health conditions, including diabetes and cardiovascular disease, but fail to receive adequate care (De Hert et al. 2011).

The historical lack of alignment in the financing and delivery of physical and behavioral health care as well as other supportive services for individuals with behavioral health conditions has contributed to gaps in the quality of their care and to their use of costly services. Indeed, individuals with SMI have high rates of emergency department (ED) visits and inpatient hospitalizations (Durden et al. 2010; Greenberg 2012). Research has found that individuals with mental illness are one of the costliest groups of Medicaid recipients (Kronick et al. 2009). Among Medicaid beneficiaries with chronic physical conditions, health care costs for those with a mental illness are as much as 75 percent higher than for those without a mental illness (Boyd et al. 2010).

Concerns regarding the quality and costs of care for this population have prompted Medicaid programs, managed care organizations (MCOs), and state and county mental health agencies to seek better strategies for financing and delivering services that integrate and coordinate physical and behavioral health care as well as other supportive services (Greenberg 2012; Kim et al. 2012). There is currently tremendous variation in the financing arrangements and delivery models used to provide care for this population. In many states and communities, physical health care and behavioral health care are provided in different service settings that receive reimbursement through distinct financing arrangements. While some state Medicaid programs provide both physical and behavioral health services using a fee-for-service model, many states contract with MCOs to provide physical and/or behavioral health services and/or managed behavioral health organizations (BHOs) to provide behavioral health services. Some states also seek to improve the coordination of services through enhanced primary care case management (PCCM) programs that provide enhanced payments to providers and other incentives and tools to ensure that individuals receive comprehensive services. Finally, certain supportive services that are often necessary for this population--including peer support, employment assistance, and housing and transportation services--are often provided outside of the auspices of state Medicaid programs, managed care arrangements, or state or county behavioral health agencies.

Each of these financing arrangements and delivery models has both strengths and limitations. As policymakers continue to look for ways to improve care for this population, they need detailed information about how states and communities are aligning the financing and delivery of services to strengthen the integration and coordination of physical, behavioral, and other supportive services for individuals with behavioral health conditions. To provide such information, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) contracted with Mathematica Policy Research to conduct case studies of the financing arrangements and delivery models use to provide behavioral health services for Medicaid beneficiaries in four states: Louisiana, North Carolina, Tennessee, and Vermont. The case studies profile and describe the different mechanisms for coordinating and integrating services, including the financing of those services, the data infrastructure and information systems used, and the quality monitoring practices. These case studies were not intended to evaluate the effectiveness or outcomes of the programs; rather, they sought to profile each program and provide information that other state Medicaid programs and mental health agencies could use to inform the design of their own services. These case studies may also provide a foundation for further research focused on these programs.

Through document review and discussions with stakeholders in each state, the case studies sought to answer the following overarching questions:

  • What are the goals of each program and in what context did each develop?

  • How and to what extent are physical health, behavioral health, and other supportive services (housing, transportation, employment supports, and so on) covered and/or coordinated within each program?

  • How is each program financed? Does the program draw from different funding sources and/or pool funds from multiple state agencies or payers?

  • What are the intended outcomes? How are the quality of care and outcomes measured and monitored?

  • What information systems and data infrastructure support the program?

Chapter II provides a brief summary of the methods used for the case studies. The subsequent chapters describe the key features of each state program. Appendix A contains a profile of each program.

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