Program successes. Both the Bureau of TennCare and the MCOs consider the integration efforts a success. The bureau believes that it has implemented a fully integrated health care delivery system that provides comprehensive care for the whole person. There is no thought of returning to the earlier BHO model. The earlier model did not encourage providers to see patients frequently. The state's quality and cost outcomes are moving in the right direction, and TennCare members are receiving more services now than they did before the integration took place. Effectiveness of care measures, including the treatment of behavioral health conditions and medication management, have continued to show improvement. The proportion of TennCare CHOICES members receiving home or community-based care has also improved (Bureau of TennCare 2012b).
Representatives from both TennCare and the MCOs assert that costly treatments have been reduced for both behavioral and physical health services. Specifically, MCOs have seen a reduction in inpatient utilization, especially for long-term stays. The MCOs have taken advantage of the supportive housing benefit to move patients out of hospitals and into community-based alternatives. MCOs have reported their inpatient and subacute numbers have gone down, and their outpatient numbers have gone up.
State MCOs and providers have embraced integration. Integration was made easier because the incentives of the state, the providers, MCOs, and beneficiaries were aligned: everyone desired fewer ED visits and hospitalizations. The stakeholders with whom we spoke said that providers and patients have also welcomed the integration. Many members are more comfortable accessing behavioral health services through their PCP than in some other way and are happy to be getting comprehensive care.
Challenges encountered. Although TennCare providers have in general embraced integration, some behavioral health providers were initially apprehensive that the MCOs would not understand behavioral health care. Further, representatives from an MCO indicated that some PCPs were afraid to screen for behavioral health issues because they were unsure how to proceed if the screen was positive. Concerns from both the provider and MCO perspective were soon alleviated as integration moved forward successfully.
The Bureau of TennCare said that getting behavioral health providers to adjust to a different type of management style was challenging. Although they were used to a managed care model, their payment methodologies had been "grant-like" under the state's BHO model. The community mental health centers, in particular, were used to delivering services under the old payment system and had to be taught the skills needed under the new system. The state worked closely with them to educate them on issues such as billing for services, submitting claims in a timely manner, getting prior-authorization, and so on. As one respondent said, "The community mental health centers were not a very sophisticated group of providers from a business standpoint. The behavioral health providers all have more of a fee-for-service atmosphere now and were ultimately supportive of the integration."
To address challenges at the provider level, MCOs have implemented various initiatives. Specifically, Volunteer State Health Plan said that it has conducted trainings for providers on crisis services. It also has a PCP referral line that allows the PCP to speak with clinical staff. Nurses will call members and make appointments for them. The MCO also has psychiatric consultations available for the provider and is currently pursuing the outreach initiative with the local American Academy of Pediatrics mentioned above. The MCO is also focusing on expanding behavioral health in primary care, especially in rural areas.
Advice for other states. Representatives from the Bureau of TennCare said that in the past year, over half of states have requested guidance from the bureau on various topics, including integration. They acknowledged that integration may have been easier in Tennessee because the state had experience with managed care for physical health services. But overwhelmingly, they recommended that other states should integrate their behavioral and physical health programs.
TennCare representatives said that working with providers is critical, and that states must remember that an integrated health care system is a partnership. Before they implement anything states must understand providers' point of view; states must also help providers to get where they need to be after the implementation. Although members of the mental health advocacy community might worry that individuals will not receive behavioral health services in an integrated system, the respondents said that this is not the case. They advised bringing the behavioral health community into the conversation and emphasized the importance of a detailed and hands-on approach to monitoring the MCOs and providers. When the integration started, the bureau closely monitored the numbers and types of claims coming in, and it has continued to do so. The Bureau keeps close tabs on what providers are doing.
The stakeholders also advised states to think carefully about the MCO procurement process and about implementation. Providers should know what they are bidding on. Contracts with MCOs should be detailed, with each requirement carefully defined. Educating providers, particularly the community mental health centers, is important, and should be undertaken even on tasks such as filling out claims. Community mental health centers should be aware of the opportunities that integration opens up (for example, case managers in the centers can now help people get their physical health services, too).
Regarding data and quality initiatives, TennCare representatives said that prompt access to reliable encounter data is very important because hard data make it possible to correct misinformation based on anecdotes. Quality requirements should be spelled out in the MCO RFP, and an independent review such as those conducted by an EQRO can go a long way in dispelling stakeholder concerns. Different types and levels of incentives and sanctions can be used to ensure compliance. The respondents also advised states to consider using a state-level satisfaction survey (for example, CAHPS) since these will allow the state to track satisfaction over time.