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


Program successes. Over its history, CCNC notes a number of accomplishments. First, the program has achieved widespread engagement of PCPs; currently, 90 percent of primary care services are delivered to Medicaid beneficiaries via CCNC-affiliated primary care medical homes. In addition, CCNC has successfully built upon the existing health care infrastructure in North Carolina rather than completely revamping the way care is financed and delivered.

Evaluations of the program suggest it has resulted in both improved care and cost savings (Kaiser Commission on Medicaid and the Uninsured 2009). An external actuarial analysis by Mercer, Inc., estimated that, compared with historical fee-for-service costs, CCNC's care management and quality-improvement activities in 2006 saved the state between $154 and $170 million (Steiner et al. 2008). This figure grew to $194 million by 2009 (CCNC 2013d). The largest savings accrued from reduced ED, outpatient, and pharmacy costs. A separate external evaluation by the University of North Carolina at Chapel Hill compared outcomes and costs for individuals enrolled in the CCNC pilot versus the Carolina Access (PCCM) program in 2000-2002. The study estimates that during this period, the CCNC's asthma management program saved $3.5 million and the diabetes management program saved $2.1 million, largely the result of lower ED and hospital use (Ricketts et al. 2004).

Challenges encountered. As noted previously, North Carolina is currently implementing a managed care carve-out for all behavioral health services. Eleven separate full-risk MCOs will be implemented throughout 2013, each with different policies and procedures. This change has posed a challenge for CCNC in managing care for enrollees with SMI. The LME-MCOs have adopted a utilization review process which can delay treatment. In addition, the LME-MCO's criteria for selecting patients for care management now differs from CCNC's criteria. These issues complicate the hand-off between the CCNC care managers and the LME-MCO care managers; CCNC is currently working with the LME-MCOs to improve this process.

Lessons learned. CCNC representatives feel that there is no one-size-fits-all program. A successful program must be tailored to the unique needs and goals of each state and target population. Program representatives recommended moving beyond the traditional health care delivery model and reorganizing care delivery to center around the patient. CCNC has developed an alternative, primary care intervention approach in which mental health issues are caught (and milder issues treated) in the primary care setting. In this way, many patients can receive needed behavioral health care in a setting that is familiar and comfortable.

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