What Are We Learning about Behavioral Health Integration? States Gather to Learn

Promoting the operational, financial, and administrative integration of behavioral and physical health services (behavioral health integration or BHI) remains a focal point for state health policy leaders as they look at ways to improve the health of populations.

BHI models are well supported by research evidence—summarized in several Fund reports, but complex to design and implement. They require state agencies involved in different components of BHI to work together and decide on the specific scope of services and the providers to be included, and how BHI performance will be evaluated and incentivized.

BHI is a priority area of the Reforming States Group (RSG), a nonpartisan, voluntary group of state health policy leaders from both the executive and legislative branches supported by the Fund. In response to interest from the RSG, the Fund brought together eight states earlier this year for a day-and-a-half of presentations and discussions to help them learn about operational changes that could advance their BHI efforts.

Each participating state brought a team of senior representatives from their Medicaid and behavioral health-related agencies. Prior to the meeting, state teams assessed their current status—and what they wanted to accomplish in three areas: incorporating BHI requirements into Medicaid managed care contracts; selection of quality and performance measures; and development of new payment models that reflect the state’s BHI goals. Participants were given information about new federal requirements for Medicaid managed care and data sharing, as well as examples from other states pursuing similar strategies in the three areas.

What are we learning about BHI?

• Most states are using some form of managed care contracting, but there are a wide variety of models that address behavioral health. These are typically referred to as “carve-in” and “carve-out” programs, since they assign responsibility for mental health services to one agency or another. For example, a recent issue brief published by the Commonwealth Fund, How Arizona Medicaid Accelerated the Integration of Physical and Behavioral Health Services, profiles how that state recognized that a BHI model was needed to better coordinate care across these systems for Medicaid beneficiaries with complex health and behavioral health needs. They merged state agencies responsible for these programs, thus advancing a strategic approach to contracting, funding, and measuring services for these populations.
• For states with managed care contracting, contracts need to specifically address BHI and include requirements for quality measures and value-based purchasing (VBP) that are specifically designed to advance BHI. VBP policies will include incentives and possibly penalties tied to BHI structural elements, care processes, and outcomes.
• States want providers to be successful participating in VBP so as not to disrupt access and clinician-patient relationships. As a result, states should consider a gradual phase-in of VBP policies to determine their feasibility and effectiveness, and give MCOs and providers time to adapt. For BHI and VBP to succeed, states need to define specific responsibilities for their MCOs regarding provider support and practice transformation. Providers need assistance with new operational functions such as managed care contracting, billing, implementation of electronic health records, and partnering with other providers. In particular, providers who specialize in substance abuse disorder have less experience and capacity in these areas, and will need specific attention to assist in the transition.
• States are also considering opportunities for multi-payer coordination in support of BHI in an effort to bring about consistency of measures and incentives, and reduce unnecessary complexity and burden.
• Significant policy and technical barriers remain with data sharing, which is an essential component of BHI.
• Current BHI programs are generally focused on non-elderly adults; there are questions about how to adapt these models to other populations, including children and the elderly.

After the meeting, each participating state developed a short-term action plan to advance their specific models. The Fund is following up with each state to document their progress and any obstacles they’re facing. In addition, the Fund will conduct an in-depth review of VBP policy and operations across different state models. Further development of this information will not only help the states that participated in the meeting, but also will be shared broadly with other states interested in advancing BHI.