Opportunities for Behavioral Health Transformation: Making Change
This article includes excerpts from Atròmitos President Michealle Gady’s Opening Plenary Session entitled “Inspiring Change Makers for Awesome” at The i2i Center for Integrative Health’s Visionary Voices Conference.
Over the past decade, public behavioral health systems across the country have undergone one transformation after another. As a result, providers and system stakeholders are often left feeling like just when one transformation finishes it’s time to start over again. As you can imagine, this continual state of transformation is difficult to manage. Why? Because transformation is change. And, in life, we know that even though change is a constant, it’s hard. To change the world, you have to change the way you see it. You have to change the way you operate in it. You have to change your approach.
The approach to behavioral health transformation today is being fueled by the concepts of holistic person-centered care and integrated care. These ideas reach far beyond the behavioral health system alone and require engagement and collaboration with other sectors of the healthcare system. But this is just the “how”. Transformation of this magnitude isn’t just a moment—it’s a movement. And to build this movement it’s critical to start with the “why.”
People with mental and substance abuse disorders often die decades earlier than the average person — mostly from untreated and preventable chronic illnesses like hypertension, diabetes, obesity, and cardiovascular diseases. And often times, these illnesses are aggravated by poor health habits such as inadequate physical activity, poor nutrition, smoking, and substance abuse. Barriers to primary care — coupled with challenges in navigating complex healthcare systems — have been a major obstacle to care. At the same time, primary care settings have become the gateway to the behavioral health system, and primary care providers are lacking the support and resources needed to screen and treat individuals with behavioral and general healthcare needs.
Ultimately the challenge that we face today is to redefine how we think about health, not just physical health or behavioral health, but health overall. Medicaid transformation presents an opportunity to do just that. No one sector of the healthcare system can do it alone. But if we’re able to harvest the collective wisdom of all stakeholders in the public healthcare system, we really can redefine health not just as the absence of disease, but as our true, whole, authentic well-being. That is person-centered care.
And there’s a growing body of evidence that person-centered care means positive outcomes and experiences for people receiving care and for the workforce. While the evidence is new, the potential is widely recognized. Study after study, evaluation after evaluation have found that the implementation of person-centered initiatives and practices can lead to significant improvements in satisfaction and experience of care, as well as improved perceptions of provider organizations from the community. Studies have also shown that person-centered approaches can lead to improvements in workforce attitudes, job satisfaction, emotional stress, and overall workforce wellbeing. Still other studies have found that person-centered care is associated with improvements in safety, quality, and clinical outcomes. Improved mortality rates. Decreased readmission rates. Reduced length of stay and improved treatment adherence.
The question is, if we know that’s the end state, if we know that the “why” of Medicaid Transformation and person-centered care is to redefine health as whole well-being, how do we get there? How do we even begin to define what person-centered care is in real-terms?
Many believe the solution lies in integrated care, the systematic coordination of general and behavioral healthcare. Integrating mental health, substance abuse, and primary care services produces the best outcomes and proves the most effective approach to caring for people with multiple healthcare needs. However, this approach is a significant change from the historical siloed-nature of mental health treatment in the United States. It requires building new competencies and relationships both within the behavioral health system between mental health and substance use disorder systems as well as across systems that treat physical health needs. These new models of care not only require providers to change how they deliver care, but they require consumers to change how they seek care, and payers to change how they reimburse for care. There are several different approaches being taken to address these needs and, below, we will provide some examples of how federal and state partners are working to transform the Medicaid behavioral health system.
Federal Approaches to Behavioral Health Transformation
Medicaid is the single largest payer of behavioral health care in the United States, covering more than a quarter of adults with a serious mental illness (SMI). However, only 65 percent of the 10.4M adults with a SMI received mental health services in 2016. To address these shortcomings in the system, the Centers for Medicare and Medicaid Services (CMS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) have been developing new demonstrations and funding opportunities to enable states to redesign – or transform – their public health care systems and improve access to behavioral health and physical health services.
Section 1115 Demonstration Waivers offer states the flexibility to design and improve their Medicaid programs and to demonstrate and evaluate state-specific policy approaches to better serve Medicaid populations. Current and pending Section 1115 behavioral health waivers address four main areas:
The use of Medicaid funds to pay for substance use and/or mental health services in “Institutions for Mental Disease” (IMDs);
The expansion of community-based behavioral health benefits;
The expansion of Medicaid eligibility to cover additional people with behavioral health needs; and
Reform of financing delivery systems, such as physical and behavioral health integration or alternative payment models.
To date, the opioid epidemic has been the primary driver for states seeking 1115 Waiver authority to improve behavioral health delivery. For example, in December 2016, CMS approved a section 1115 demonstration project for Virginia that authorizes the state to strengthen its SUD delivery system to improve the care and health outcomes for Virginia Medicaid beneficiaries. Virginia’s new SUD benefit and delivery system, called the Addiction and Recovery Treatment Services (ARTS) Delivery System Transformation, expanded the SUD benefits package to cover the full continuum of care, integrating SUD services into comprehensive managed care. According to CMS, early results in Virginia show a 39 percent decrease in opioid-related emergency room visits, and a 31 percent decrease in substance-use related ER visits overall after implementation of the demonstration.
According to SAMHSA’s 2014 National Survey on Drug Use and Health, approximately 7.9 million adults in the United States had co-occurring disorders— the coexistence of both a mental health and a substance use disorder—in 2014. As such, many states have requested waiver authority that would enable them to expand access to community and residential treatment services for mental health disorders in addition to the current SUD authority. In recognition of this need, CMS released a State Medicaid Director Letter on November 13, 2018 that describes a new waiver authority—the SMI/SED Demonstration Opportunity. CMS has created this opportunity to allow states to design innovative service delivery systems for adults with SMI and children with serious emotional disturbance (SED). States will be able to receive authority to pay for short-term residential treatment services in an institution for mental disease (IMD) for these patients.
States participating in the SMI/SED Demonstration Opportunity will be expected to commit to taking a number of actions to improve community-based mental health care and meet the goals CMS has established for the SMI/SED demonstration opportunity. According to the SMD Letter, these goals will include “actions or milestones to ensure good quality of care in IMDs, to improve connections to community-based care following stays in acute care settings, to ensure a continuum of care is available to address more chronic, on-going mental health care needs of beneficiaries with SMI or SED, to provide a full array of crisis stabilization services, and to engage beneficiaries with SMI or SED in treatment as soon as possible.”
Certified Community Behavioral Health Centers (CCBHCs) were created through Section 223 of the Protecting Access to Medicare Act (PAMA), which established a demonstration program based on the Excellence in Mental Health Act (Excellence Act). The Excellence Act demonstration program is a two-year, 8-state initiative to expand Americans’ access to mental health and addiction care in community-based settings. The Excellence Act established a federal definition and criteria for a new Medicaid provider type—CCBHCs—and stipulated that CCBHCs may receive an enhanced Medicaid reimbursement rate based on their anticipated costs of care. CCBHCs are responsible for nine required types of services, with an emphasis on the provision of 24-hour crisis care, utilization of evidence-based practices, care coordination, and integration with physical health care. Ultimately, the demonstration program is expected to infuse more than $1.1 billion into community-based services, making it the largest investment in mental health and addiction care in decades.
In December 2016, SAMHSA announced the selection of the eight participating states: Minnesota, Missouri, Nevada, New Jersey, New York, Oklahoma, Oregon and Pennsylvania. Starting in 2017, these eight states collectively launched 66 CCBHCs. In April 2018, the National Council for Behavioral Health surveyed CCBHCs to find how their participation has affected their capacity to expand and improve services. Survey results confirm that when community behavioral health clinics are incentivized to provide evidence-based care they can transform access to care in their communities. These clinics are:
Increasing access to mental health and addiction treatment;
Expanding capacity to address the opioid crisis;
Collaborating with partners in hospitals, jails, prisons and schools; and
Attracting and retaining qualified staff who offer science-based, trauma-informed services – often on the same day patients present for care.
State Approaches to Behavioral Health Transformation
While many states are leveraging these federal authorities to enact change in their behavioral health systems, they must work within or modify their existing delivery system and payment structures which vary from state to state (managed care, fee-for-service, value-based payment). As such, each state’s path to transformation is different. But understanding how other states have addressed challenges and barriers can be beneficial to stakeholders in states that are just beginning down the road to transformation.
Washington State’s Fully Integrated Apple Health (Medicaid) program has changed how it pays for delivery of physical health, mental health, and SUD services. The program has brought together the payment and delivery of physical and behavioral health services for people enrolled in Medicaid under integrated managed care plans. Through this whole-person approach to care, physical and behavioral health needs are addressed in one system through an integrated network of providers, offering better coordinated care for patients and more seamless access to the services they need. This is one effort under the state’s broader Healthier Washington initiative, which also included the goal of shifting 80 percent of state health care purchasing from paying for volume to paying for value.
The state pursued integrated managed care to improve the experience of Medicaid consumers so that ultimately, they had better access to care they needed to stay healthy. Before care was integrated, Medicaid clients with co-occurring disorders had to navigate three separate systems in order to access the physical and behavioral health services they needed. The physical health, mental health, and substance use disorder delivery systems often didn’t communicate, which led to duplication of services, poorly coordinated care, lower health outcomes, and a frustrating experience for Medicaid consumers and the providers who served them. Through Fully Integrated Managed Care plans, Medicaid consumers continue to have access to physical and behavioral health services but are supported by a single health plan that is responsible for integrating care to meet the individual’s holistic needs. Preliminary findings of an evaluation of the implementation of FIMC in the first region of the state (Southwest) found that out of the 19 outcome measures analyzed:
10 showed statistically significant relative improvement for Medicaid beneficiaries residing in the SW Washington region
1 showed a statistically significant relative decline in the SW Washington region (ED utilization per 1,000 coverage months)
Colorado’s State Innovation Model (SIM) is helping primary care practice sites to integrate behavioral and physical health in primary care settings and learn how to succeed with alternative payment models. CMS awarded Colorado up to $65 million to implement and test its proposal. The overarching goal of Colorado’s SIM is to improve the health of Coloradans by increasing access to integrated physical and behavioral healthcare services in coordinated community systems leveraging value-based payment structures for 80 percent of state residents by 2019. The plan, called The Colorado Framework, creates a system of supports, both clinic-based and through expanded public health efforts, to spur integration.
Research has shown that providing integrated, or 'whole-person' healthcare is beneficial both to the patient as well as the provider. Colorado’s SIM proposal states that “while integrated care is necessary, it is not sufficient to achieving the healthiest state possible. We recognize that health outcomes are strongly impacted by social, economic and environmental factors.” Based on the social determinants of health model, the Colorado SIM proposal leverages the efforts of public health to support the clinical health transformation. Therefore, the state’s integration efforts are being supported by an improved public health infrastructure. In turn, it is the state’s intention that behavioral health integration will improve population health by addressing behavioral factors that often impede the management of chronic health problems, especially obesity, smoking, and diabetes.
Prior to bringing any practices onboard, seven of Colorado’s health insurers agreed to coordinate with the SIM Office to support efforts through the development of clinical models and value-based payment systems to incentivize participating primary care practices. Changing the payment model from one based on fee-for-service was designed to ensure that the newly integrated system is sustainable for care providers, health plans, and patients.
The resources from SIM are supporting the integration of physical and behavioral healthcare in hundreds of primary care practices and four community mental health centers, expanding health information technology efforts, including telehealth, leading a robust evaluation program that measures both processes and outcomes, finalizing our statewide plan to improve population health, and helping to bring commercial and public health insurance carriers together to support practices with alternative payment models. The SIM approach recognizes that providers have varying levels (six levels) of readiness for integration and has developed its approach to supporting practices by recognizing where the practice is at and where it can successfully move to within the course of the initiative. The SIM initiative ends in July 2019.
Arizona’s Regional Behavioral Health Authorities (RHBAs) have been the long-time administrators of behavioral health services for individuals with serious mental illness. Behavioral health was carved out of the Arizona Healthcare Cost Containment System (AHCCS) managed care entities that managed physical health services for the Medicaid population. Because of this structure, an individual with SMI may have had to interact with up to four different health care systems to obtain health care: the AHCCCS acute health plan for physical health services; the RBHA for behavioral health services; Medicare for persons with SMI who are dually eligible for both Medicaid and Medicare; and Medicare Part D for medications.
To help address these issues, AHCCCS collaborated with behavioral health partners to create a more streamlined system aimed at reducing barriers to care for members and increasing accountability of the RBHA for managing the “whole health” of persons with SMI. Beginning in 2014 this new structure was phased in regionally across the state, RBHAs managed the delivery of physical health services, in addition to behavioral health services, to increase member engagement in obtaining medically necessary physical health services.
While members with an SMI were enrolled in the RHBAs and had a single entity managing their physical and behavioral health needs, behavioral health remained carved out of the traditional AHCCS plans. The state developed Arizona Complete Care to provide all Medicaid members with an integrated health plan. Long-term services and supports are not included under this program and are managed separately under Arizona’s Long Term Care System (ALTCS) managed care program. The state allowed RBHA contractors the option to compete to become an ACC contractor.
AHCCCS Complete Care (ACC) began on October 1, 2018. This new integrated system joined physical and behavioral health services together to treat all aspects of member health care needs under a chosen health plan. AHCCCS Complete Care encourages more coordination between providers within the same network which can mean better health outcomes for members. While at this time AHCCS serves individuals with SMI under a separate program when the RHBA contracts expire Integrated ACC plans will have the opportunity to compete for expansion of services to include members with SMI and other non-AHCCCS eligible members.
In these states and in others across the country we have made a lot of progress, but we still have a lot of work to do to achieve truly person-centered care. To get at the “why” of complete well-being we need to achieve:
Care that is delivered in partnership with individuals and their caregivers.
Care that is integrated and organized around the need of people and not diagnosis.
Care that is delivered by trusted systems where collaboration occurs at all levels.
Care where individuals and families maintain control and their goals, preferences and values are respected and honored.
Through system transformation – and Medicaid transformation, specifically – we can do better by creating a system that focuses on the whole person, and not just their illness. It is not just a problem, an assessment that has to be done, or a prescription that needs to be written. Through transformation we can do better by creating a truly person-centered system of care. At its core, person centered care is about compassion. It’s about empathy. At its core, it’s about our humanity.
 SAMHSA. What is Integrated Care? Available at https://www.integration.samhsa.gov/about-us/what-is-integrated-care
 Kaiser Family Foundation. Facilitating Access to Mental Health Services: A Look at Medicaid, Private Insurance, and the Uninsured. November 2017, available at https://www.kff.org/medicaid/fact-sheet/facilitating-access-to-mental-health-services-a-look-at-medicaid-private-insurance-and-the-uninsured/
 Kaiser Family Foundation. Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers. September 20, 2018. Available at https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-demonstration-waivers-the-current-landscape-of-approved-and-pending-waivers/
 Centers for Medicare and Medicaid Services, CMS Announces New Medicaid Demonstration Opportunity to Expand Mental Health Treatment Services. November 13, 2018. Available at https://www.cms.gov/newsroom/press-releases/cms-announces-new-medicaid-demonstration-opportunity-expand-mental-health-treatment-services
 Washington State Healthcare Authority. Integrated Physical and Behavioral Health Care. Available at https://www.hca.wa.gov/about-hca/healthier-washington/integrated-physical-and-behavioral-health-care