All Together Now: Integrating Behavioral Health and Primary Care in Medicaid

Research suggests that people with serious mental illness die about 25 years sooner than the general population.  The cost of care for those with serious mental illness—and behavioral health disorders more broadly—is also formidable.  According to a recent study from New York, total health care costs for Medicaid enrollees who have behavioral health disorders are about 35 to 44 percent greater than costs for the general Medicaid population.
Behavioral health issues are common among the population that will become eligible for Medicaid in 2014:

• About 7 percent have a serious mental illness,
• About 15 percent suffer from serious psychological distress, and
• About 14 percent have a substance use disorder.

Integrating behavioral health and primary care can help the newly Medicaid eligible (and other enrollees) manage mental health and substance abuse issues.  This can improve quality of life, enable self-management, and avoid undesirable acute care utilization.
Here are a few examples of the many forms that integration can take:

• Screening, brief intervention, and referral to treatment (SBIRT): SBIRT, typically performed by a paraprofessional located at a primary care practice, entails systematically identifying and supporting individuals with substance abuse issues. SBIRT has producedreturns on investment of 380 percent and greater when targeted at risky alcohol use.  The model has been adapted for use with other conditions as well, such as depression.  TheWisconsin Initiative to Promote Healthy Lifestyles is one of many groups that promote the use of SBIRT.

• Enhanced coordination between behavioral health providers and primary care providers: Primary care providers (PCPs) can address many behavioral health needs, but individuals with more intense needs may require additional support.  Coordination helps ensure that PCPs can easily refer patients to specialists when appropriate, that needed information flows back and forth between providers, and that PCPs feel confident treating patients with behavioral health conditions.  In addition, programs that support consultation with psychiatrists or other experts can help PCPs better manage patient needs.  TheMassachusetts Child Psychiatry Access Program is an example of this approach.

• Co-location of behavioral health providers and PCPs: Enabling and encouraging behavioral health providers and primary care providers to practice at the same site can facilitate whole-person care.  Co-location also promotes “warm-handoffs,” whereby a patient can visit with a behavioral health provider immediately after a physical health appointment.  The Washtenaw Community Health Organization in Ypsilanti, Michigan has supported the spread of integrated clinics.

States can use several policy levers to facilitate integrated care in Medicaid:

• Pay for what you want, and set clear expectations: Wisconsin Medicaid pays about $35 for a behavioral health screening and $20 per 15 minutes of intervention.  States can also emphasize that behavioral health care is an essential component of Early and Periodic Screening, Diagnostic and Treatment (EPSDT).  For example, Massachusetts providers seeing children with Medicaid coverage must offer to perform a behavioral health screening at EPSDT well-child visits.  Screening rates have soared since the requirement was put in place.

• Reexamine billing restrictions: Limits on billing for multiple same-day encounters (common particularly for health centers) can discourage integrated care, especially warm-handoffs.  In addition, some states limit the types of providers who can bill for offering a given service.  Tennessee is one state that has successfully addressed these issues.

• Carefully craft new benchmark benefit packages: Those newly eligible for Medicaid must be offered “benchmark” or “benchmark-equivalent” coverage. The essential health benefits—which include behavioral health services—must be covered, but states have some discretion in determining what is included.  States may choose to provide additional services tailored to those with behavioral health needs, such as additional mental health or care coordination services.

• Align with medical home/health home initiatives: States can set standards that encourage or require medical homes and health homes to integrate care.  For example:

• Payment to practices in the multi-payer Rhode Island Chronic Care Sustainability initiativewill soon vary in accordance with performance on screening for depression (among other measures).
• Community Care of North Carolina includes behavioral health providers in the networks that serve patients of multiple practices.
• One of Missouri’s health home state plan amendments (SPAs) requires health homes to screen for behavioral health conditions.
• Rhode Island has developed a health home SPA for individuals with serious and persistent mental illness receiving integrated care through community mental health organizations.

Both Missouri and Rhode Island are receiving 90 percent federal financial participation for health home services delivered to eligible Medicaid enrollees with chronic conditions during the first two years that their health home state plans are in effect.
Is your state integrating behavioral health and primary care?  What models are you using?  Are there any early in-state successes that you can build on?  Tell us in the comments below.