[for Part 1, click here.]
The waves of changes in health care have been flowing (crashing?) over us for the past couple years. One can barely get dry before the next one comes on. In psychiatry, we have several big waves hitting us now. Adoption of electronic health records. DSM-5. Integration of mental health, addiction, and somatic health care.
Integration of health care, to me, seems like the most challenging one. It involves changing many of our beliefs and practices about how behavioral health (I am using this BH term to encompass both mental health and addiction treatment) care is provided. Much of this new direction has been driven by a series of factors, including the Mental Health Parity Act of 1996, the New Freedom Commission report in 2002, and the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008.
A good resource for the MHPAEA is parityispersonal.org. The ultimate realization of parity, and of the end of the stigma so long attached to behavioral health, is the full integration of BH into the rest of health care, in the same way that cardiology and neurology are both integrated into health care. There is not a separate health insurance company to manage cardiology services. Neurology patients do not have to pay a higher co-pay for neurology services than they do for other specialty care services. And when you need to find a cardiologist in your insurance company’s provider directory, they are listed there with the other specialties, not in some other directory on some other website.
In my July 2012 column, entitled Health Care Integration, I discussed the process of integration in Maryland Medicaid and promised an update. Every state is addressing this to varying degrees and at different paces. Maryland’s efforts are led by Health Secretary Joshua Sharfstein, a pediatrician and public health expert who clearly gets the value of integration, and Chuck Milligan, the deputy secretary overseeing the entire project. A long process of stakeholder meetings culminated on Oct. 1 in a final recommendation report that can be found at http://dhmh.maryland.gov/bhd/SitePages/integrationefforts.aspx.
The report concludes: “While noting the strengths in the current system, including generally good access in each service domain (mental health, substance use treatment, and somatic care), the resulting report reached five conclusions: (1) benefit design and management across the domains are poorly aligned; (2) purchasing and financing are fragmented; (3) care management is not coordinated; (4) performance and risk are lacking; and (5) care integration needs improvement.”
The current system includes several managed care organizations (MCOs) that provide somatic and addiction care services, and a single administrative services organization (ASO) – Value Options – that is responsible for mental health services. The final recommendation to Secretary Sharfstein is “that Maryland pursue a transformative behavioral health carve-out that combines treatment for specialty mental illness and substance use disorders under the management of a single administrative services organization (ASO).” The transformation part refers to the development of a “performance-based ASO,” whose features include the following:
- Financial performance risk (likely including shared savings) at the ASO level;
- Financial performance risk (which could include shared savings) at the behavioral health provider level;
- Incorporation of behavioral health financial incentives at the primary care and MCO level; and
- Incorporation of non-financial tools that distinguish providers who achieve positive outcomes from providers who achieve average or poor outcomes, including tools such as differential rules for prior authorization, utilization review, and consumer self-referral.
Other changes might include greater integration between the ASO and the MCOs:
- Requiring an MCO to assign a care coordinator when one of its members receives services in the specialty behavioral health system;
- Developing policies and approaches to coordinate (or integrate) primary care with the specialty behavioral health services provided through the new behavioral Health Home;
- Increasing bi-directional data sharing between the MCOs and the ASO to improve beneficiary care, which could include an approach that aligns electronic health records; and
- Shared savings models across somatic and behavioral health.
I think we are moving in the right direction, despite some criticism in the path to get there. We are making less of an issue now about what model to choose (Model 2 has been chosen, the ASO model), and beginning to focus more on the details. Based on the Principles of Integration from the Maryland Psychiatric Association (enumerated in Part 1 of this series), the last four points, such as care coordination, bi-directional data-sharing, shared savings and risk, and stakeholder oversight and data transparency, are all elements that MUST (not “may”) be included.