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ImprovingMentalHealthServicesIntegrationinMedi-Cal:StrategiesforConsideration

LenFinocchio,Dr.P.H.KatrinaConnolly,Ph.D.MatthewNewman,M.P.A.

May2017

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TableofContentsExecutiveSummary........................................................................................................................31.Purpose......................................................................................................................................62.Approach....................................................................................................................................63.Introduction...............................................................................................................................74.ServiceDeliveryChallengeswiththeCurrentSystem................................................................75.ObstaclestoReform.................................................................................................................106.PolicyStrategiesandMechanismsforStimulatingReformsandImprovements....................126.1OverarchingStrategiestoDevelopandAdvanceIntegrationSolutions............................136.1.1ImproveQuantificationandUnderstandingofIntegrationIssues..............................136.1.2DrawLessonsfromRelatedMedi-CalPilotsandInitiativesforHigh-NeedPatients..146.1.3TargetedMHSAFundingforIntegrationEfforts.........................................................15

6.2OptimizePresentEnvironment..........................................................................................166.2.1RevisittheStakeholderProcesstoImproveUnderstandingandDevelopNext1915(b)Waiver..................................................................................................................................166.2.2SupportOrganizationalandCulturalChangestoIntegrateBehavioralHealthinManagedCarePlans.............................................................................................................176.2.3Implement“NoWrongDoor:PayandChase”Policies...............................................186.2.4IncentivizeCoordination.............................................................................................186.2.5ImproveMOUsandContractsBetweenCountiesandPlans......................................186.2.6DevelopMHPs“ManagedCare”FunctionsandCapacity...........................................196.2.7ImproveIntegrationviaMedicaidQualityRequirementsandReporting...................206.2.8LeverageNewMedicaidManagedCareRegulationstoPromoteReform..................216.2.9ExpandUseofTele-PsychiatrytoAddressWorkforceShortage.................................226.2.10EncourageHealthPlansandCountiestoShareProviders........................................22

6.3SolutionsforPartialIntegration.........................................................................................236.3.1IntegrateFinancialRisk...............................................................................................236.3.2CountyMHPsAssumeFullResponsibilityforMild,Moderate,andSevereMentalHealthServices.....................................................................................................................256.3.3CountyMHPsAssumeFullResponsibilityforAllServicesforSMIpopulation............25

6.4Longer-termChange:FullIntegrationbyEndingthe“CarveOut”....................................26AppendixA:CurrentDataCollectionandReportingEfforts........................................................29

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ExecutiveSummary

Purpose

Thispaper,commissionedbytheBlueShieldofCaliforniaFoundation,describessomeofthecurrentchallengesfacingCalifornia’ssystemofmentalhealthservices,exploresstrategiesforimprovingmentalhealthintegration,andproposesscenariosforchangingaspectsoflaw,policyandorganizationalpracticesthatcouldpromoteimprovedintegration.

FullIntegrationbyEndingthe“CarveOut”

Themosteffectivewaytoaddresstheproblemsofsiloedcareistoconsolidatetheresponsibilityfordeliveringthefullrangeofmentalhealthservices,frommildtosevere,withinasingleentity.Suchanapproachwouldalignincentivessuchthattheentitypayingformentalhealthserviceswouldbeencouragedtoprovideearlyinterventionandcarecoordinationservicessoastoreducelongtermcostsforbothphysicalandmentalhealthconditions.Themostambitiousandeffectivesolutionwouldbetointegratephysicalhealth,mildandmoderatementalhealth,andspecialtymentalhealthunderasingleentity,presumablyMedi-CalManagedCarePlans(MMCPs).Althoughthesechangesaresubstantial,theywouldnotnecessarilyresultinincreasedstatecoststotheextentcurrentservicelevelsaremaintained.Inthenear-term,utilizationratesforphysicalhealthservicesfortheSMIpopulationcouldincreaseasaresultofincreasedaccesstocare,buttheseincreasescouldbeoffsetbylong-termsavingsasaresultofavoidedhospitalizationsandreducedemergencydepartmentuse.IntegratingallMedi-Calphysicalandmentalhealthserviceswould,however,beaHerculeantaskandwouldlikelyrequireaballotinitiative,legislativeandregulatoryactions,approvalfromthefederalgovernment,andactionsbyBoardsofSupervisors,allofwhichposepoliticalandadministrativechallenges.Inspiteofthelargepotentialbenefits,theseobstaclesmeanthatfullsystemicintegrationisaverychallengingscenario,atleastinthenear-term.Giventhemanyobstaclesto“fullintegration,”thispaperpresentsseveralshortandmedium-termstrategiesforimprovingthesystemofdeliveringmentalhealthservicesandbetterintegratingphysicalandmentalhealthcare,particularlyforthosewithseverementalhealthneeds.Thesestrategiescanhelpmovethestatetowardfullintegrationasalonger-termgoal.

StrategiestoDevelopandAdvanceIntegrationSolutions

Severalstrategiescouldhelptoimproveintegrationandpatientcare,regardlessofwhetheranyoftheotherstrategiessuggestedinthisreportareadopted.These“overarching”strategiesincludedevelopinganimprovedunderstandingoftheimpactofthecurrentbifurcatedsystemandstudyinganddrawingconclusionsfromrelatedpilotprogramsalreadyunderway,suchasWholePersonCareandtheHealthHomesInitiative.

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Inadditiontotheseoverarchingstrategies,anumberofstrategiescouldbeemployedtohelpoptimizethepresentenvironment(evenintheabsenceofmorecomprehensiveintegrationefforts)orputinplacetheneededfoundationsfordevelopinglonger-termreform.Forexample,developingimprovedMemorandaofUnderstanding(MOUs)orcontractsbetweencountiesandhealthplanscouldhelptomoreclearlydelineaterolesandresponsibilitiesandreduceconfusionandredundancy.EnablinghealthplansandcountiestoshareproviderscouldallowpatientswithmoderatementalhealthconditionsthatneedtomovebetweentheMMCPandtheMHPtostaywiththesameprovider,whileexpandeduseoftele-psychiatrycanhelptoalleviateworkforceshortages.And,countiesandplanscouldbeencouragedtoimplementa“NoWrongDoor”policysuchthatpatientswouldreceiveneededcareattheirfirstpointofcontactwiththehealthcaresystem,withpaymentarrangementsworkedoutbehindthescenesbetweenthecountyMHPandtheMMCP.Finally,supportfordevelopingcounties’“managedcare”functionsandcapacitycouldhelpcountiestobetterplanforandmanagefinancialrisk,developapanelapproachtohealthmanagement,andimplementcomprehensivequalityimprovementstrategies.Beyondthesesortsofeffortsaimedatbettercoordinationamongcountiesandplans,existingreportingandqualityimprovementprogramscouldbeleveragedtomonitorprogressandincentivizereform.Forexample,bothMMCPsandMHPscurrentlyworkwithExternalQualityReviewOrganizations(EQROs)tosubmitqualityimprovementandperformancemeasurementreportstoDHCS.DHCScouldaddintegration-relatedmetricstomanagedcareandcountycontractsandincludetheminqualityreporting.Inaddition,MMCPsandMHPsalreadyundertakePerformanceImprovementProjects(PIPs).DHCScouldencouragespecificPIPswithamentalhealthintegrationfocusandprovidetoolsforactingonthesestrategies.TheseeffortstoleverageexistingreportingandqualityimprovementeffortscouldbecombinedwithanefforttoleveragethenewMedicaidmanagedcareregulationstopromotereform.Finally,asthestatepreparesforthecomingexpirationofthecurrent1915(b)waiver(in2020),muchworkcanbedonetoencourageaculturalshifttowardintegrationthatbenefitscurrentpatientsandbuildsafoundationforpotentialfuturefinancialintegrationwiththenextwaiver.

SolutionsforPartialIntegration

Beyondthesestrategiestooptimizethecurrentenvironmentandlaythefoundationforfutureintegrationefforts,someinterimsolutionsaimedatpartialintegrationneverthelesshavethepotentialtoimprovepatientcareandoutcomesintheshorterterm.OnepotentialsolutionwouldbeselectedpilotprojectswhereincountieswouldcontractwithMMCPs,whowouldassumefinancialandcareresponsibilityforservicesthecountiescurrentlydeliver.Underthisscenario,theproviderscouldremainthesame(throughacontractarrangement)butthefinancialriskmanagementoccurswithonepayer.Thisconsolidatedfinancialmanagementwouldimproveincentivesforearlyinterventionandcoordinatedpatientcarebothacrossthemildtoseverecontinuumandbetweenmentalandphysicalhealth.

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Analternativetothisarrangementwouldbeapilotapproachinwhichcountiescouldassumeresponsibilityforallmentalhealthservices(mildtosevere).Thiswouldleveragecountymentalhealthserviceinvestmentandexpertiseandcouldalignfinancialincentivesforearlyinterventionandfollow-upcareaftercrisis.YetanotheralternativewouldbeforcountyMHPstoassumefullresponsibilityforallphysicalandmentalhealthservicesfortheSMIpopulation,therebyaddressingtheseparationbetweenphysicalandmentalhealthprovidersforthispopulation.Eachoftheseapproacheshascertainlimitations,but,becausetheycouldbeimplementedvoluntarilythroughcontractsbetweenplansandcounties,theyhavetheabilitytobeimplementedintheneartermonapilotbasis.Ifcarefullyevaluated,theresultscouldbeusedasimportanttoolsforinforminglonger-termstructuralreforms.

FundingforIntegrationEfforts

Fundingforintegrationstrategiescouldcomefromseveralsources,butthetwomostpromisingarefundsfromtheMentalHealthServicesAct(MHSA)andfoundationfunding.BoththelocalaswellasstateportionsofMHSAfundsrepresentarelativelyflexiblefundingsourceformentalhealthservices.Foundationfundingcouldalsobeusedtoincentivizeintegration,supportresearchandanalysis,ortoprovidetechnicalassistanceforcountiesandplansinterestedinexploringintegrationstrategies.

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1.Purpose

Thispaper,commissionedbytheBlueShieldofCaliforniaFoundation,describessomeofthecurrentchallengesfacingCalifornia’ssystemofmentalhealthservices,exploresstrategiesforimprovingmentalhealthintegration,andproposesscenariosforchangingaspectsoflaw,policyandorganizationalpracticesthatcouldpromoteimprovedintegration.Thesestrategiesarepresentedforconsiderationbyhealthphilanthropies,Medi-Calmanagedcareplansandcountyspecialtymentalhealthplans,stateagenciessuchastheDepartmentofHealthCareServicesandtheMentalHealthServicesActOversightCommission,andotherorganizationsandadvocatesfocusedonmentalhealth.ThispaperwascompletedinFall2016,beforethechangeinadministrationinWashington.WhilespecificchangestoMedicaidareuncertainasofthiswriting,therecentAmericanHealthCareActandrelatedproposalsclearlyintendtoconstrainfederalMedicaidcontributions.TotheextentfederalMedicaidfundingisreduced,Californiawouldfaceservingbeneficiarieswithfewerfederalresources,andconsequently,wouldlikelyexpandtheuseofvalue-basedstrategies.Manyoftheproposedstrategiesinthispapercouldallowthestatetooptimizetheuseoflimitedresourceswhileimprovingaccessto,andthequalityofhealthservices.

2.Approach

Toresearchandwritethispaper,weundertookanextensiveliteraturereview,includingacademicpapers,stateandfederalcontracts,policydocumentsandotherreports.Wealsoconducted36interviewswithrepresentativesfromthefollowing:

• Countymentalhealthdirectorsandexperts• CaliforniaDepartmentofHealthCareServicesleadership• MentalHealthServicesActexperts• AdvocatesforMedi-Calbeneficiaries• ConsultantswithexpertiseinbehavioralhealthandMedicaid• Behavioralhealthcareproviders• Publichospitalsandcommunityhealthcenters• Medi-Calmanagedcareplans• Managedbehavioralhealthorganizations• Countyfinancingexperts• CentersforMedicareandMedicaidServices• Healthphilanthropyexecutivesandprogramofficers

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3.Introduction

AlthoughsignificantlystrengthenedbytheAffordableCareAct(ACA)andotherrecentpolicychanges,California’shealthcaresafetynetremainsafracturedsystemthatmakesitdifficulttomeetallofasafetynetpatient’sphysicalandmentalhealthneeds.Thesystemdesignatesresponsibilityforthephysicalhealthand“mild-to-moderate”mentalhealthconditionsofMedi-CalbeneficiariestoMedi-Calmanagedcareplans(MMCPs)andresponsibilityforprovidingservicesfor“severementalillness”tocountyspecialtymentalhealthplans(MHPs).1Thissystemcanbecharacterizedbymisalignedincentivesandpotentiallylargegapsinpatientcare.Exemplarycoordinationeffortscanimprovethepatientexperience,buttheyareexpensiveandoftennotcost-effective.Further,beneficiaries’experienceofthiscoordinationdependsonrelationshipsbetweenpayersthatvaryovertimeandacrosscountiesandmanagedcareplans.Thisfragmentedsystemofdeliveringcarehasevolvedoverseveraldecades.Thislonghistorymeansthatmanypolicies,customs,andsystemsmaybeentrenched,whilerecentpolicychangesmeanthatmanywhoworkinthismaybesubjectto“policyfatigue.”Asaresult,implementinglarge-scalestructuralchangestothiscaredeliverysystemmaybedifficult.Legalrestrictionsonfundingstreams,lackofinstitutionalcapacityamonghealthplans,bureaucraticinertia,andevenashortageofqualifiedmentalhealthprovidersallserveasobstaclesinthepathoffundamentalstructuralchanges.Theremainingsectionsofthisreportpresentanassessmentofthechallengescausedbythecurrentfragmentedsystem,identifythecontextualfactorsthatmayhinderreforms,andoutlinesomepotentialstrategiestoimproveintegration.Thesechallenges,context,andstrategiesfocusonimprovingthesystemofdeliveringmentalhealthcareservices,particularlybyintegratingservicesforthosewithmild-to-moderateconditionswithservicesfortheseverelymentallyill(SMI)andintegratingbothphysicalandmentalhealthservicesinonesystem.Therealsomaybepotentialforimprovementsinthebroaderbehavioralhealthsystem(i.e.mentalhealthplussubstanceusedisordertreatment).Becausethesubstanceusedisordersystemiscurrentlyundergoingaseparatereformeffort,however,discussionsofbehavioralhealthintegrationbroadlyarenotafocusofthisreport.

4.ServiceDeliveryChallengeswiththeCurrentSystem

California’scurrentsystemeffectuatestwopartitionsinservicedelivery,onealongthecontinuumofmentalhealthservicesandtheotherbetweenmentalandphysicalhealthservicesforpatientswithseverementalillness.Thebifurcationofmentalhealthcareformild-to-moderateandSMIpatientscancreatecounter-productiveincentivesforpatientcare.Forexample,counties’haveafinancialincentivetoavoididentifyingpatientsatthe“high-

1Foranoverviewofthesystem,themostrecentpaperis:LewisK,CoursolleA.MentalHealthServicesinMedi-Cal.NationalHealthLawProgram.IssueBrief.January17,2017.http://www.healthlaw.org/publications/search-publications/Mental-Health-Services-in-Medi-Cal

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moderate”levelasSMI.2However,managedcareplansareresponsibleforprovidingmild-to-moderateservices,butdonotbearthecostsofprovidingmentalhealthservices(atthesevereendoftreatmentcontinuum)totheSMIpopulation.3Consequently,countieshavelimitedabilitytointerveneearlyandpreventaseriousmentalhealthcrisis,orprovidefollow-upcareafterapatientisstabilizedfollowingsuchacrisis.Medi-Calmanagedcareplanscanexperienceasavings(atleastintermsofmentalhealthcosts)onceapatiententersthecountyspecialtymentalhealthsystem.4Inadditiontomisalignedfinancialincentives,thelimitedclinicalrationaleforthecurrentseparationofmentalhealthservicesmakesitdifficulttoestablishclearcriteriaforassigningpatientstoonecaresystemoranother(e.g.responsibilityfor“high-moderates”).5WhileMemorandaofUnderstandingbetweenMHPsandMMCPsrequiredisputeresolution,thismechanismmaybeinsufficienttodevelopdelineatedresponsibilitiesorencouragepatientcarecoordination.Consumerconfusionoverpayerresponsibilitycanalsoleadtodelaysincare.Thebifurcatedsystemoftreatmentalsodisregardsthedynamicnatureofmentalillness.Intervieweesdescribedhowconditionscanfluctuatealongthementalillnessspectrum,resultingina“pingpong”dynamicasapatientmovesbetweentheMHPandMMCP,withtheresultbeingpoorcontinuityandcoordinationofcare.AdmittancetothecountyMHPgenerallyrequiresareferralforaninterview,treatmentauthorization,andultimatelyreferraltoaprovider.TransferfromtheMHPtoaMMCPproviderformild-to-moderateservicesisalsoreferral-based.Patientswithmentalillnesscanhavedifficultyfollowingthroughwithreferrals,exacerbatingthedifficultiesassociatedwithtransitionsamongproviders.6Moreover,withlittleornodataexchangethereislimitedcapacityforMMCPandMHPproviderstotrackreferredpatientsandensuregoodpatientcarecoordination.7

2Somecountiesmay“ration”specialtymentalhealthservicesbyapplyinganoverlyrigidinterpretationofthemedicalnecessitycriteria.Seepage26of“AComplexCase:PublicMentalHealthDeliveryandFinancinginCalifornia,”CaliforniaHealthCareFoundation,2013. http://www.chcf.org/publications/2013/07/complex-case-mental-health.3ThecostofamentalhealthcrisisintheformofanEmergencyDepartmentvisitwouldbebornebytheMMCP,butissubstantiallylesscostlyrelativetothecosttothecountyofprovidinginpatientpsychiatriccare.4Somecasesofseverementalillnesscannotbepreventedwithmildandmoderateservices,andsomemildandmoderateconditionsleftuntreatedwillnotacceleratetoseverementalillness.However,highqualitypreventativeandmildandmoderateservicesforsomeconditionssuchasdepression,eatingdisorders,andtraumacanpreventcrisisandaneedforspecialtymentalhealthservices.HighqualityMCPservicesfollowingamentalhealthcrisisaremostcriticaltoprevententrancetothecountysystem,butnofinancialincentiveputspressureontheMCPtoensurethequalityoftheseservices.5Partofthedefiningcriteriaforseverementalillness,“functionalimpairment,”leavessomeroomforinterpretation,andmayvarybycounty.6SomecountiesretainsomemoderatepatientsevenwhenacasecouldbemadefortheirtransitiontoaMMCPproviderforfearthatthesepatientswoulddestabilizeandreturntothecountyafteranattempttotransition.7MMCPsandcountiesdonotexchangepatientdatabecauseseparatedatasystemsareincompatibleandduetoconcernsaboutprotectingpatientprivacyandassociatedlegalrestrictions.

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MildandModerateServicesinAreaswithWorkforceShortagesInsomecounties,alackofavailablementalhealthproviderscompoundsservicedeliveryproblems.Inparticular,ashortageofpsychiatristscanleadtocompetitivebehaviorsbyMHPsandMMCPs(e.g.disallowingco-certification)tomonopolizeaprovider’savailability.Someremoteareashavesofewpsychiatriststhattele-psychiatryistheonlyaccessoption.SomeintervieweesreportedthatthelocalMMCPwasnotprovidingsufficientmild-to-moderateservicesduetoworkforceshortages.8InadequatePhysicalHealthCareofPatientswithSevereMentalIllnessInadditiontoaforementionedcoordinationandtransitionchallenges,theSMIpopulationfrequentlydoesnotreceiveadequatephysicalhealthcare.9ThisisparticularlyconsequentialgiventhehighprevalenceofcomorbiditiesandbehavioralandsocialriskfactorsintheSMIpopulation.10Despitethesehighriskfactors,datasupportsintervieweeassertionsthatmanySMIpatientsdonotreceiveadequateprimarycare.Forexample,individualstreatedforSMIanddiabetesusetheemergencydepartmenttwiceasmuchasindividualstreatedonlyfordiabetes.Similarly,inpatientstaysaretwiceascommonfordiabetespatientswithSMIascomparedtodiabetespatientswithoutSMI.11InresponsetothedeficienciesinprovidingprimarycareservicestoSMIpatients,somecountieshavetakentheinitiativeandusedMentalHealthServicesAct(MHSA)fundsandSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA)grantstofundclinicstoprovideprimarycarefortheirSMIpatientseventhoughMMCPsarefinanciallyresponsibleforthephysicalhealthcareforthesepatientstotheextenttheyareeligibleforMedi-Cal.WhydoMMCPsStruggletoAdequatelyProvideCarefortheSMIPopulation?TheSMIpopulation’sphysicalhealthcareisexpensive.OfthemostcostlyfivepercentofMedi-Calbeneficiaries,45percentaretreatedforseverementalillness.12InterviewssuggestthatMMCPsstruggletomeetSMIpatients’healthneedsbecausethisrequiresintensive

8IntervieweesreportedthatsomecountiesprovidemildtomoderateservicesintheabsenceofMMCPservices.9NumerousintervieweesemphasizedthatmostMCPsarenotprovidingprimarycareand/orarenotmeetingthephysicalhealthneedsoftheSMIpopulation.10Parks,J.SvendsenD,SingerP,FotiME,MauerB.2006.“MorbidityandMortalityinPeoplewithSeriousMentalIllness,”NationalAssociationofStateMentalHealthProgramDirectors,SeriesofTechnicalReports,October.http://www.nasmhpd.org/sites/default/files/Mortality%20and%20Morbidity%20Final%20Report%208.18.08.pdf11“UnderstandingMedi-Cal’sHigh-CostPopulations,”DHCSResearchandAnalyticStudiesDivision,2015,Slide38.http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20D/PDF%20DataSymposium03042015Watkins.pdf12“UnderstandingMedi-Cal’sHigh-CostPopulations,”DHCSResearchandAnalyticStudiesDivision,2015,Slide14.http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20D/PDF%20DataSymposium03042015Watkins.pdf

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coordinationthatcanincludeoutreachandengagement,clinicalinformationsharing,medicationreconciliation,andpatientandfamilyengagement.13SuchcarecoordinationrequiresfinancialinvestmenttypicallynotcoveredbyMedi-Cal(exceptbyrecentpilotprograms).14,15,16Perhapsmoreimportantly,deliveringphysicalhealthcaretotheSMIpopulationrequiresprimarycareproviderwillingnesstotreatanoftenstigmatizedpopulation.

5.ObstaclestoReform

Giventhemyriadproblemswiththecurrentbifurcatedsystemofdeliveringmentalandphysicalhealthcare,whydoessuchasystempersist?Perhapsthesimplestansweris“history.”Inotherwords,thesystem’sevolutionovermanydecadesandtheassociatedinertiamakereformdifficult.Trulyintegratingmentalhealthcareandphysicalcareservicedeliverywouldrequirestatelegislationtorevisit“Realignment”andmightalsorequireaballotinitiative.OverviewofCurrentFundingMechanismsEstimatedbehavioralhealthfundingtotalsover$8billionforfiscalyear2016-17.Themainfundingsourcescomprising$7.5billionofthesefundsarethefederalmatchingfundsforMedi-Calmentalhealthservices($3billion),MHSAfunds($1.7billion),the2011Realignmentforbehavioralhealthservices($1.4billion),andthe1991realignmentformentalhealthservices($1.3billion).17The1991and2011Realignmentscreateddedicatedrevenuesourcesforbehavioralhealththatareoutsideoftheannualstatebudget.The1991Realignmentfundshavebeenusedforservicessuchaslockedlong-termpsychiatricfacilitiesandindigentphysical

13“CareCoordinationforPersonswithComplexMentalHealth,SubstanceUseandMedicalConditions:TheCaseforHealthPlansandOtherPayers,”IntegratedBehavioralHealthProject,CaliforniaMentalHealthServicesAuthority,page1.http://www.ibhp.org/uploads/file/BusinessCasePayersFinal.pdf14ibid15ForadiscussionofMedicaidreimbursementforcarecoordination,see“ReimbursementofMentalHealthServicesinPrimaryCareSettings,”U.S.DepartmentofHealthandHumanServices,SAMHSA,2008,page20.http://www.integration.samhsa.gov/Reimbursement_of_Mental_Health_Services_in_Primary_Care_Settings.pdfCarecoordinationisbillabletoMedi-Calforpatientsage21andunder,see“AComplexCase:PublicMentalHealthDeliveryandFinancinginCalifornia,”CaliforniaHealthCareFoundation,2013,pages23-34;and“MHSDInformationNoticeNo.:13-11,”DepartmentofHealthCareServices.http://www.dhcs.ca.gov/formsandpubs/Documents/13-11.pdfSeveralnon-Medi-CalfundingstrategiesandpilotinitiativeshaveaddressedcarecoordinationformentalhealthpatientsinCaliforniainthepastdecade,suchasMHSA-fundedFullServicePartnerships,foundation-fundedpilots,andSAMHSAgrants.Mostrecently,HealthHomesandWholePersonCarepilotsarefundingcarecoordinationnotcurrentlyreimbursableunderMedi-Calsuchasjointcareplandevelopmentandinterdisciplinarycareteammeetings.(See“AComplexCase:PublicMentalHealthDeliveryandFinancinginCalifornia,”CaliforniaHealthCareFoundation,2013,pages29,34-35.http://www.chcf.org/publications/2013/07/complex-case-mental-health.)16Recentpilotprograms,WholePersonCareandHealthHomes,areaimedinpartataddressingtheneedforbettercarecoordinationforpatientsinparticipatingareas.17MaryAderandTomRenfree,“Updateonthe2016-17StateBudget,”CountyBehavioralHealthAssociationofCaliforniaMemorandumtoCBDHAmembers,July6,2016,http://www.cbhda.org/wp-content/uploads/2014/12/CBHDA_Memo_Members_2016-17_State_Budget_07-06-16.pdf

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healthcare,andfortheMedi-Calstatesharematch.The2011Realignmentfundsdrugandalcoholtreatment,Medi-Calmanagedcareprogramsformentalhealth,andMedi-Cal’sEarlyandPeriodicScreening,Diagnosis,andTreatment(EPSDT)program.Thestateretainslimitedauthorityindirectingtheuseofrealignmentfundsbeyondensuringthatfundsareusedinamannerintendedbytherealignmentstatutes.18Inaddition,currentlawprohibitsthestatefrompassingmandatesthatwouldleadtoincreasedcountycostswithoutadditionalfunding(Proposition30).19Becausethecurrentsystemoffundingmentalhealthservicesisbasedonaseriesofballotpropositionsandotherstatelawsandregulations,makingsignificantchangestothissystemwouldrequirerevisitingmanyofthesehistoricalfundingarrangements,includingsomeestablishedbyvoters.It’sNotJustRealignmentFullyintegratingmentalhealthcarewouldalsorequirechangesinthestate’sMedicaidSection1915(b)SpecialtyMentalHealthWaiver.Since1995,thiswaiverestablishedcounty-operatedhealthplansforspecialtymentalhealthservicesthereby“carvingout”theseservicesfromMedi-Calmanagedcareplans.20Beyondlegalandfinancialissues,institutionalfactorsalsoactasobstaclestoreformefforts.Endingthe“carveout”wouldtransferSMIresponsibilityfromthecountiestoMMCPs,potentiallydislocatingthecountymentalhealthworkforceandotherproviders.Moreover,manycountyBoardsofSupervisorsmayresistrelinquishingcontrolthefinancingstreams,providingtheseservicesandemployingthisworkforce.ManagedCarePlansHaveLimitedCapacitytoDeliverSMIServicesManyMMCPsmaylacktheexpertiseandcapacitytomanagetheSMIpopulation.Thesepatientshavecomplexmentalhealthneeds,andcountieshavedeepexperiencewiththispopulation.Incontrast,mostMMCPshavelimitedexpertiseandcapacity,havingonlyrecently

18Realignment2011(AB114)transferredresponsibilityandfundingformentalhealthservicesforstudentswithdisabilitiesinschoolsfromthecountytothedepartmentofeducation.Now,mentalhealthservicesforthesestudentsarefundedbythestategeneralfundviaProposition98,federalIDEAfunding,andMHSA.Countiescontinuetofundmentalhealthservicesfornon-specialeducationstudentsthroughEPSDTandMHSAfundedearlypreventionprograms.Seepage25“AComplexCase:PublicMentalHealthDeliveryandFinancinginCalifornia,”CaliforniaHealthCareFoundation,2013.http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20C/PDF%20ComplexCaseMentalHealth.pdfandhttp://www.dhcs.ca.gov/services/MH/Documents/CSI_2013_06_03c_AB_3632_AB_114b.pdf.19“LocallySourced:TheCrucialRoleofCountiesintheHealthofCalifornians,”2015.http://www.chcf.org/publications/2015/10/locally-sourced-crucial-role-counties20“AComplexCase:PublicMentalHealthDeliveryandFinancinginCalifornia,”CaliforniaHealthCareFoundation,2013,page13.http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20C/PDF%20ComplexCaseMentalHealth.pdf

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assumedresponsibilityformild-to-moderateservices.CountiesandadvocatesmayhaveconcernsaboutiftheMMCPcapitationmodelsufficientlyincentivizeshigh-qualitycare.21SystemReformFatigueandUncertaintyTheremaybelimitedappetiteamongcountyandhealthplanleadershiptotakeonsuchasystemtransformationgivenotherchangescurrentlyunderway,suchastheWholePersonCarepilots,HealthHomesProgram,andtheDrugMedi-CalOrganizedDeliverySystempilots.Notonlyhasimplementingthesechangesconsumedleaders’attentioninmanyorganizations,butsomeintervieweesclaimtheexpandedserviceneedhascontributedtoashortageofavailablementalhealthproviders.Inaddition,uncertaintymayserveasanotherimportantobstacletochange.BothMMCPsandMHPswilllikelybeconcernedabouttheuncertaincostofintegratingsystemsandtheextentofpotentialsavings.And,ofcourse,themostuncertaineventualitycurrentlyistheextentofanyforthcomingchangestotheAffordableCareActandMedicaidthatmaycomefromWashington.Ultimately,withoutasignificantincentivetochangethecurrentsystem,thecurrentlegal,regulatory,culturalandinstitutionalbarrierstoreformarelikelytoprevail.

6.PolicyStrategiesandMechanismsforStimulatingReformsandImprovements

Theobstaclestoreformnotwithstanding,itisclearthatthecurrentbifurcatedsystemofdeliveringmentalhealthservicesisnotservingpatientswell.Potentialimprovementstothissystemspanacontinuumfromstrategicandnear-termimprovementstocomprehensiveandlong-termtransformation.Belowwepresentsolutionsalongthiscontinuuminfourcategories:

1. Overarchingstrategiestodevelopandadvanceintegrationsolutions2. Strategiestooptimizethepresentenvironment3. Partialintegrationapproaches4. Long-termchange

21ForcontractstrategiestoholdMMCPsaccountableforprovidingqualitybehavioralhealth,see“EnsuringAccesstoBehavioralHealthcarethroughIntegratedManagedCare:OptionsandRequirements,”NationalCouncilforBehavioralHealth,2014.http://www.thenationalcouncil.org/wp-content/uploads/2014/11/14_Managed-Care-2.pdf;Seeexamplesofotherstatesthatintegratehealthcareundermanagedcareplanattachfinancialrewardsandpenaltiestoperformancemetrics:KanCareFinalEvaluationDesign,KansasDepartmentofHealthandEnvironment,DivisionofHealthCareFinance,March2015.http://www.kancare.ks.gov/download/KanCare_Final_Evaluation_Design_Revised_March_2015.pdfAnd“AttachmentII,ExhibitII-C–EffectiveDate:July15,2015,SeriousMentalIllnessSpecialtyPlan,”FloridaAgencyforHealthCareAdministration,July2015.https://ahca.myflorida.com/medicaid/statewide_mc/pdf/Contracts/Exhibit_II_C-Serious_Mental_Health_Illness_2015-07-15.pdf

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Thesestrategiesarepresentedforconsiderationbyhealthphilanthropies,Medi-Calmanagedcareplansandcountyspecialtymentalhealthplans,stateagenciessuchastheDepartmentofHealthCareServicesandtheMentalHealthServicesActOversightCommission,andotherorganizationsandadvocatesfocusedonmentalhealth.

6.1OverarchingStrategiestoDevelopandAdvanceIntegrationSolutionsWepresentthreestrategiesthatwouldoptimizethepresentenvironmentandadvancelonger-termchange.Detailedbelow,theseincludedatacollectionandanalysis,drawinglessonsfromon-goingpilots,andhelpingcountiesbetteruseMHSAfunds.

6.1.1ImproveQuantificationandUnderstandingofIntegrationIssues

Althoughproblemswiththebifurcatedsystemarewellknown,datatoquantifytheirextenthasnotbeenwidelyorsystematicallycollected.Morecomprehensivedataareneededtoassessthecontinuityofmentalhealthcare,measuretheextenttowhichphysicalhealthconditionsofindividualswithSMIareaddressed,andestimatethecostofcoordinatingservices(seeAppendixAforadiscussionofcurrentdatacollectionefforts).22Thedatarecommendedbelowwouldsystematicallyilluminateintegrationchallengesandpointtosolutions:

● ContinuityofCare-Littleisknownabouttheextent,severityandcostsofdelayedcare.TheNationalHealthLawProgrampresentsseveralcaseexamplesthatillustratethenatureofproblemsforpatientsmovinginabifurcatedmentalhealthsystem.23But,additionaldataareneededtounderstandhowmanypeoplearenotreceivingtheneededmentalhealthcareservices.Inaddition,dataareneededtoknowhowmanypeoplearebeingtreatedorgivenanin-takeassessmentformentalhealthservicesbythecountyspecialtymentalhealthplan(MHP)andreferredtotheMMCPforservicesbutdonotreceiveservices(andviseversa).Metricsoffollowupcareafteracrisisandthenumberandfrequencyofrecurrentmentalhealthcrisesmayalsocontributetounderstandingtheextentofproblemsstemmingfromthebifurcatedsystem.Discerningwhichproblemsaremostwidespreadandcontributemostpotentlytopatienthealthandhighercostswouldhelpdirectpolicyattentionandresources.

● PhysicalhealthneedsofSMIpopulation-IndividualswithSMIcandie,onaverage,25yearsearlierthanthosewithoutSMI,mostlyfromtreatablehealthconditions.24More

22StatewidedatacollectioneffortsfocusonthecarequalityprovidedbyMHPsandMMCPsseparately.Evaluationsofcarecoordinationpilotsanddemonstrationsmayyieldinformationimprovingintegration.SeeAppendixA.23LewisK,CoursolleA.MentalHealthServicesinMedi-Cal.NationalHealthLawProgram.IssueBrief.January17,2017.http://www.healthlaw.org/publications/search-publications/Mental-Health-Services-in-Medi-Cal24Parks,Joe,DaleSvendsen,PatriciaSinger,MaryEllenFoti,andBarbaraMauer.2006.“MorbidityandMortalityinPeoplewithSeriousMentalIllness,”NationalAssociationofStateMentalHealthProgramDirectors,SeriesofTechnicalReports,October.http://www.nasmhpd.org/sites/default/files/Mortality%20and%20Morbidity%20Final%20Report%208.18.08.pdf

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specificdataondifficultiesinmeetingthephysicalhealthneedsofindividualswithSMIareneeded.DatasharingeffortsbetweenMHPsandMMCPscouldyieldinformationontheextenttowhichphysicalhealthcareisavailableandaccessibletotheSMIpopulationbyusingspecificmetrics,suchasthepercentoftheSMIpopulationwithaphysicalhealthdiagnosisthatsawaproviderforthatconditionwithinaspecifiedperiod.25

● Costsofcoordination-Thecostsofcoordinatingcareacrosstwosystemsarelikely

greaterthanthecostsofcoordinatingcarewithinasinglesystem.QuantifyingthesecostswouldrequiredevelopmentofamethodologytoidentifycoordinationcostsoccurringinMHPsandMMCPs.

● MMCPandMHPlandscape-EvaluatingMMCPsintermsoftheircapacitiestomanage

behavioralhealthisanimportantstepforexploringstrategiesthatprepareMMCPsfortakingonfullfinancialriskfortheSMIpopulation.CriteriawouldneedtobedevelopedtoevaluateMMCPbehavioralhealthcapacity(suchasstaffwithbehavioralhealthexpertise,providerpanels,incorporatingarecoverymodel),amongothercriteriatobedeveloped.26

AnotherusefuldatacollectioneffortwouldidentifyMHPsthatcontractouttheirbehavioralhealthservices.SuchplansmaybemoresuitableorinterestedinparticipatinginapilotthatalignsfinancialresponsibilityforallhealthcareintheMMCP.Finally,datacollectionthatcomparesthesupplyofbehavioralhealthproviderstoserviceneedbyMHP,MMCP,andmanagedbehavioralhealthorganizations(MBHO)wouldidentifyareaswithworkforceshortages.

6.1.2DrawLessonsfromRelatedMedi-CalPilotsandInitiativesforHigh-NeedPatientsTherearenumerouspilotsandinitiatives,eitherunderwayoronthecuspofimplementation,thatwilladvancecarecoordinationforhigh-needMedi-Calbeneficiaries.Most,ifnotall,oftheseincludeindependentevaluationsandrequiredmonitoringbyDHCSandCMS.Theseinclude:theWholePersonCarepilots,27HealthHomesProgramforPatientswithComplex

25SeeaWebinarhostedbytheCaliforniaHealthCareFoundationthathighlightsresearchbyuniversityresearchersthatusedMedi-CaldatatostudythecharacteristicsandneedsoftheSMIpopulation.DHCSstaffdiscussedimplicationsofthefindingsforpolicy.“Webinar--UsingMedi-CalDatatoImproveCareforSeriousMentalIllness,”CaliforniaHealthCareFoundation,January12,2016,http://www.chcf.org/events/2015/webinar-medical-mental26Thiswouldcouldbuildonworkthatidentifiedcountieswhereplansoffermildtomoderateservicesin-housevs.throughasubcontractedMBHOintheCaliforniaHealthCareFoundationreport,“TheCircleExpands:UnderstandingMedi-CalCoverageofMild-to-ModerateMentalHealthConditions,”August2016,http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20C/PDF%20CircleMediCalMentalHealth.pdf27CaliforniaDepartmentofHealthCareServices,“WholePersonCarePilots,”webpage,http://www.dhcs.ca.gov/services/Pages/WholePersonCarePilots.aspx

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HealthNeeds,28DrugMedi-CalOrganizedDeliverySystempilots,29andtheCoordinatedCareInitiative.30Inadditiontothesestatewidepilotsandinitiatives,therearenumerouslocalorregionalcollaborationswhoseclinical,financing,policyandoperationalinnovationscouldrenderlessonstoimprovementalhealthintegrationandfinancialrisksharing.Furthermore,theMedicaidInnovatorAcceleratorprogram’sworkonintegrationcouldalsorendervaluablelessons.31Thefieldat-largewouldbewell-servedbya“meta-analysis”oftheevaluationresultsandfindingsfromthesemanypilotswithrelatedobjectivesandmyriadapproachestoachievingthoseobjectives.32Thisworkmightinclude:

● Compilinganinventoryofthesenumerouspilotsandinitiatives,reportingandevaluationrequirements,andevaluators(ifcontracted)

● Ananalyticalapproachforthe“meta-analysis”thatwouldextracttransferrablefinancing,policyandoperationallessonsformentalhealthintegration

● Anexpertgrouptoadviseondevelopmentoftheanalyticalapproachforthemeta-analysisandpriorityresearchquestions

● Collectingandanalyzingevaluationfindingsandresultsusingthemeta-analysisapproach

● Translatingfindingsandmeta-analysisintoactionablestrategiesandprogramsforcountiesandplans,providersandadvocacygroups.

6.1.3TargetedMHSAFundingforIntegrationEffortsMHSAfundsrepresentarelativelyflexiblefundingsourceformentalhealthservicesandcouldpotentiallyincentivizemultipleproposedsolutions,althoughsomeobstaclestotheiruseexist.Whilethestatehaslimitedauthorityovercounties’useofMHSAfunds,itdoes,however,retainthreepercentofthefundsforuseinstatewideprograms.Thesefundscouldbeusedtoprovideanincentiveforcountiestopursueintegrationstrategies.Currently,thelawallowsthestateto28CaliforniaDepartmentofHealthCareServices,“HealthHomesProgram,”webpage,http://www.dhcs.ca.gov/services/Pages/HealthHomesProgram.aspx29CaliforniaDepartmentofHealthCareServices,“DrugMedi-CalOrganizedDeliverySystem,”webpage,http://www.dhcs.ca.gov/provgovpart/Pages/Drug-Medi-Cal-Organized-Delivery-System.aspx30CaliforniaDepartmentofHealthCareServices,“Medi-Cal’sCoordinatedCareInitiative(CCI):TheDualsDemonstration,”webpage,http://www.dhcs.ca.gov/dataandstats/statistics/Pages/Medi-Cal_CCI.aspx.WhiletheCCIhasbeenstatutorilydiscontinuedinthe2017-2018Budget,manyofthefeaturesofthedemonstrationwillcontinue.Moreover,theevaluationsmayoffervaluablelessons.31Medicaid,“PhysicalandMentalhealthIntegration,”webpage,https://www.medicaid.gov/state-resource-center/innovation-accelerator-program/physical-and-mental-health-integration/physical-and-mental-health-integration.html32Thisisnota“meta-analysis”asformallydefined:amethodforsystematicallycombiningpertinentqualitativeandquantitativestudydatafromseveralselectedstudiestodevelopasingleconclusionthathasgreaterstatisticalpower.Instead,weenvisionanapproachthatwouldlookcollectivelyandsystematicallyacrosslike-pilotsandextractimportantlessonsforbettercarecoordinationforhigh-needpopulations.

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collectunspentlocalfunds,butrequiresthestatetoredistributethesefundstocounties.ChangestothisarrangementcouldallowthestatetogainauthorityoverunspentlocalMHSAfundsanddirectthesefundstowardfurtheringintegrationorotherreformefforts.Inaddition,thelegislatureretainstheauthoritytoamendtheMHSAconsistentwithitspurposewithatwo-thirdsvote.Underthecurrentsystem,countieshaveconsiderableflexibilityintheuseoflocallyallocatedMHSAfunds,andcouldusethemforintegrationactivitiesifdesiredorencouragedtodoso.UndercurrentMHSAfundingallocation,countiescanuseuptofivepercentoftheirfundsforinnovationrelatedpurposes.Countiescanalsousefundsforcasemanagementorotheractivitieswhichfurtherintegration,includingtechnologicalneedssuchasimproveddatasystemstomonitorandtrackpatients.

6.2OptimizePresentEnvironment

Thesestrategieswouldbeundertakenoverthenextthreeyearsbeforethecurrent1915(b)waiverexpiresinJune2020.Theyfocuslargelyonincrementalimprovementsandbuilduponongoinginnovations,pilotsandinitiatives.Theyarealsoframedwithinexistingpolicies,rulesandregulations.Finally,theywouldbuildthegroundworkforandyieldevidencetosupportlonger-termimprovements.ThesestrategiesweredesignedbeforethenewadministrationinWashingtontookofficeandanyloomingchangestotheAffordableCareActwereimplemented.

6.2.1RevisittheStakeholderProcesstoImproveUnderstandingandDevelopNext1915(b)Waiver

Californiahasawell-establishedtraditionofinclusivestakeholderprocessestoinformthedevelopment,implementationandevaluationofMedi-Calpoliciesandwaiverprograms.Typically,thesehavebeenjointlyfundedbyfoundations,sponsoredbytheexecutivebranch,andhostedbyDHCS.Whilethisapproachisgenerallyvalued,someintervieweesperceiveditasoverlyformulaic,“toothinandtoowide,”ornotmanagedinaconstructivemanner.Numerousintervieweesadvisedkeepingthestakeholderprocessbutbringingmorefocusandrigortoit.Intervieweeslamentedthatstereotypingofmanagedcareplansandcountiespreventedcandiddiscussionsofwhatisworkingwellandwaystopromotegoodpublicpolicy.Asmallgroupofexpertscouldlaythegroundworknecessarytosupportamoreproductivestakeholderprocess.Thismightincludesmallerconveningsbetweencountiesandplanstoencouragebetterunderstandingoftheirrespectivegoals,thecommunitymentalhealthinfrastructure,andtheirrespectivecapacitiesandconstraintsaroundimprovedmentalhealthservices.33Thesediscussionsmightalsoincludepresentationsontheconvolutedhistoryof

33Oneintervieweereferredtosuchmeetingsas“peacekeeping”events.

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mentalhealthcarveoutsandcounty-staterealignmentsanddiscussionoftheresultsfromtheevaluation“meta-analysis”referencedabove.Thissmallgroupofexpertscouldalsoproposescenariosfortheoptimalpathforwardwithnewfinancingandrisk-sharingmodelsthatalignincentivesbetweenplansandcounties(asdiscussedinlaterinthispaper).Thesescenariosormodelscouldbevettedwithimportantstakeholders(e.g.Administration,DHCS,countybehavioralhealthdirectorsandplans)andthenpackagedtointroducefordiscussionintoabroaderstakeholderprocess.

6.2.2SupportOrganizationalandCulturalChangestoIntegrateBehavioralHealthinManagedCarePlans

Inthecurrentenvironmentwithfundingstreamssegregatedbyservices,muchworkcanbedonetoencourageaculturalshifttowardintegrationthatbenefitscurrentpatientsandbuildsafoundationforpotentialfuturefinancialintegration.MMCPscouldbeencouragedtodevelopabetterunderstandingofandovercometheobstaclestoprovidingbetterhealthcaretopatientswithmentalhealthneeds.Theseobstaclesmayincludealimitedtimewithpatients,lackofco-locatedmentalhealthprofessionalsinprimarycareclinicsorprimarycareprovidersinmentalhealthclinics,andlimitedawarenessofthebenefitsofearlyinterventionandpreventionformentalhealthissues.Tobuildphysicians’awarenessandskillsinmeetingthephysicalneedsofpatientswithmentalillnessandappropriatelyreferringpatientstobehavioralhealthservices,MMCPscouldoffertrainingtoprovidersinevidence-basedpracticesthataddresstheseareas.MMCPscouldalsodevelopincentivestrategiesforphysicianstogainexperiencetreatingSMIpatientsandplansthataddresstheobstaclestocareandbringaboutculturalchangesthroughtrainingandincentivesforphysicalhealthcareproviders.BuildingMMCPcapacitytotakeonfinancialriskfortheSMIpopulationrequiresamajorreorientationfromatraditionalmedicalcaremodeltoarecovery-orientedmodel.Progressalongthisroadwouldbenefitmildandmoderatepatientsaswell.TotakeonSMI,MMCPswouldneedtodevelopadeepunderstandingofbehavioralhealthandtreatmentmodalitiesandcovernon-traditionalservicesofengagement,outreach,andcarecoordination.Forexample,MMCPsusetelephonicoutreach,whichmaynotbeeffectiveformanySMIpatientswhoneedmoredirectoutreachmechanisms.Also,someMMCPsmaythinkof“carecoordination”ascoordinatingmedicalservices,butSMIpatientsneedcoordinationofphysicalhealth,mentalhealth,andsocialsupportservicesthatfalloutsideofMMCPcoveredservices(suchashousing).3434NationalCouncilforBehavioralHealth.2014.“EnsuringAccesstoBehavioralHealthcarethroughIntegratedManagedCare:OptionsandRequirements,”http://www.thenationalcouncil.org/wp-content/uploads/2014/11/14_Managed-Care-2.pdf

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6.2.3Implement“NoWrongDoor:PayandChase”Policies

Currently,neitherMMCPsnorMHPshasafinancialincentivetoquicklyresolvedisagreementsincoverageforapatient.Toreducedisputesandconfusion,thestatecouldrequiretheentitythatfirstseesapatienttoprovidecareregardlessofwhetherthepatientneedsmild-to-moderateorseverementalhealthservices.IntheeventaproviderintheMMCPfirstreceivesanSMIpatient,theMMCPinthisscenariowouldprovideandpayforcareuntilthepatientisreceivingservicesfromtheMHP.Inthiscase,theMMCPwouldhavethefinancialincentivetopursuereimbursementfromthecountyfortheinitialcareprovidedorfunded.ThepatientwouldnotexperienceaprotractedwaitingperiodduringadisputebetweenMMCPandMHP.

6.2.4IncentivizeCoordination

Thelast1115waiverrenewalstakeholderprocessdevelopedideasthatincentivizecarecoordinationthroughsharedriskandsharedsavingsmodels.35OneideawouldcreateanincentivepooltodistributefundstoMMCPsandMHPsformeetingperformancegoalsinareassuchascarecoordinationandqualityofcarefortheSMIpopulation(thisissimilartoCalMediConnectdescribedinthesection“Integratefinancialrisk”).ThisincentivecouldencourageMMCPsandMHPstojointlyfundstrategiesandpersonnelsuchasmedicationmanagersandcasemanagerstocoordinatecareandpreventcrisisandtransfertoMHPs.AnotherincentiveproposalwouldencourageMMCPstointegratephysicalandmentalhealthservicesattheproviderlevelbyofferingsupplementalcapitationpaymentsforco-locatedteambasedcare.Thesupplementalpaymentswouldbeofferedatdifferenttiersthataccommodatedifferentinfrastructurecapabilitiesofproviders.Forwidespreadadoption,DHCSwouldneedtocontractuallyrequireMMCPstoofferthesetieredsupplementalpayments.

6.2.5ImproveMOUsandContractsBetweenCountiesandPlans

CurrentMOUsbetweencountiesandMMCPscanbeverygeneralandvague.Changesthatwouldimprovetheiruseasanimprovedintegrationandaccountabilitytoolincludemorepreciselanguageonrolesandresponsibilities(particularlyforcarecoordination),specificdatareportingandsharingrequirements,andmorerigorousqualityimprovementstandards.WhileindividualcountiesandplanscanmakeMOUsmorepreciseandmoreaccountableontheirown,clearerandmorerigorousrequirements(oreventemplates)fromDHCScouldencourageimprovementsinallcounties.TheNationalHealthLawProgramhasproposednumerousrecommendationstoimproveintegration,includingimprovementstoMOUsandcontracts.36

35DepartmentofHealthCareServices.1115WaiverRenewal-MCO/ProviderIncentivesExpertStakeholderWorkgroup.http://www.dhcs.ca.gov/provgovpart/Pages/Waiver-Renewal-Workgroup-MCO-Provider-Incentives.aspx36LewisK,CoursolleA.MentalHealthServicesinMedi-Cal.NationalHealthLawProgram.IssueBrief.January17,2017.http://www.healthlaw.org/publications/search-publications/Mental-Health-Services-in-Medi-Cal

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MOUsandcontractscanalsobeusedforpurposesbeyondthegeneralimprovementsdiscussedabove.AstrategytoalignincentiveswithoutalteringthepayerstructureistodevelopasystemofsharedaccountabilitybydesigninganddeployingMOUsorcontractsthatsetqualityofcarestandardsandattachfinancialrewardsandpenaltiestoperformanceoutcomes.Thisstrategycouldencouragecarecoordinationofapatient’smentalandphysicalhealthandallowforimprovedtransparencyandaccountability.Financiallyrewardingandpenalizingbehavioralhealthprovidersforperformancemeasuresoftheirpatients’whole-personwell-beingwillincentivizethoseproviderstocoordinatewithprimarycareproviders.Similarly,rewardsandpenaltiesattachedtoperformancemetricsanddatasharingrequirementscouldencourageplansandcountiestopayforwarmhand-offsofmentalhealthpatientstransitioningbetweenMMCPsandMHPs.ThisaccountabilitysystemcouldencourageMHPsandMMCPstojointlyhireandfundstafftoprovideservicestoandcoordinatecareforthesepatients.

6.2.6DevelopMHPs“ManagedCare”FunctionsandCapacity

WhilecountyMHPsarelabeledas“healthplans,”manylackwell-developedfunctionsandcapacitiesembodiedinatraditionalmanagedcareplantoaddressfinancialrisk,apanelapproachtohealthmanagement,andcomprehensivequalityimprovementstrategies.InCalifornia’s1915(b)waiver,MHPsareclassifiedasPrepaidInpatientHealthPlans(PIHP)andarepaidonanon-riskbasis.37Inaddition,MHPsmustcomplywithspecificMedicaidmanagedcarerules,particularlyfortheavailabilityandtimelinessofservices.IntheJune2015waiverrenewal,CMSreaffirmedMHPsaccessandqualityrequirements,directedthestatetocomeintocomplianceby2020,andrequiredaMHPdashboardwithindicatorsonquality,access,timeliness,andtranslation/interpretationcapabilities.38 DevelopingdeeperandmoresophisticatedcapacitywouldallowcountiestobettercomplywiththenewfederalMedicaidmanagedcarerules,bettermanagetheirRealignmentandothermentalhealthresources,andimprovepatientcaremanagement.Thedevelopmentofsuchcapacitycouldalsohelptobuildafoundationforlong-termreformbyallowingcountyMHPsandMedi-Calmanagedcareplanstoalignfinancialandorganizationalincentivesandenterintosharedriskarrangementstobetterintegrateandcoordinatecare.Moreover,suchcapacitywouldallowcountyMHPstomanageservicesandfinancingfortheSMIpopulationbeyondmentalhealth.Forexample,managedcareplanscouldcontractwith

37CaliforniaDepartmentofHealthCareServices,“Section1915(b)WaiverProposalforMCO,PIHP,PAHP,PCCMProgramsandFFSSelectiveContractingPrograms,”June10,2015,http://www.dhcs.ca.gov/services/MH/Documents/1915(%20b)_SMHS_Waiver.pdf38CentersforMedicareandMedicaidServices,letterofapprovalandspecialtermsandconditionsforCalifornia’srequesttorenewtheMedi-CalSpecialtyMentalHealthServicesWaiver,addressedtotheCaliforniaDepartmentofHealthandHumanServices,June24,2015,http://www.dhcs.ca.gov/services/MH/Documents/Ltr_1915-b_Waiver_Amend_01_10_14.pdf

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MHPsthathavemorefullydevelopedadministrativeandmanagementcapacitytoprovidemild-to-moderatementalhealthservices.SuchcapacitydevelopmentcouldalsohelpMHPstoassumefinancialriskandresponsibilityforthefullcontinuumofbehavioralandphysicalhealthfortheSMIpopulation(theseintegrationscenariosarediscussedlaterinthepaper).ThismanagedcarecapacitydevelopmentforMHPscouldincludeallorsomeofthefollowing:

● Plandesign,financialriskmanagementandratedevelopment● Panelmanagementandpopulationhealth● Qualitymeasurementandimprovementtoolsandprocesses● Datasharing/healthinformationexchange● Networkdevelopment,adequacyassessmentandmonitoring● Providerenrollment,accreditationandsupport● Treatmentplanning,utilizationmanagement,andcarecoordination● BillingandICD-10capacity● Consumerinvolvement/memberservices

6.2.7ImproveIntegrationviaMedicaidQualityRequirementsandReportingMedicaidprogramswithmanagedcareplansarerequiredtomeetnumerousqualityassurancestandards,includinghavinganassessmentandimprovementstrategy,externalqualityreview,qualitymeasurementsandreporting,andPerformanceImprovementProjects(PIPs).39AsPrepaidInpatientHealthPlans(PIHPs),countyMHPsarerequiredbythe1915(b)waivertomeetmanyofthesemanagedcarequalitystandards.California’sMedi-CalmanagedcareplansworkwiththeExternalQualityReviewOrganization(EQRO)tosubmittheirqualityimprovementandperformancemeasurementreportstoDHCS.40CountyMHPsalsoworkwithabehavioralhealthEQROonqualityassessment,monitoringandimprovement.41Improvedbehavioralhealthintegrationcouldbepromotedusingthesequalityrequirementsandtools.Specifically,DHCScouldaddintegration-relatedmetricstomanagedcareandcountycontractsandincludetheminreportinginthePerformanceOutcomesSystemandtheMedi-CalManagedCarePerformanceDashboard.42MedicaidmanagedcareplansinFlorida,KansasandArizonaarecurrentlyusenumerousqualityandperformancemeasuresfocusedonpersonswithmentalhealthneeds.4339SocialSecurityAdministration,“ProvisionsRelatingtoManagedCare,”Section1932oftheSocialSecurityAct,https://www.ssa.gov/OP_Home/ssact/title19/1932.htm40CaliforniaDepartmentofHealthCareServices,“Medi-CalManagedCare-QualityImprovement&PerformanceMeasurementReports,”website,http://www.dhcs.ca.gov/dataandstats/reports/Pages/MMCDQualPerfMsrRpts.aspx41CaliforniaDepartmentofHealthCareServices,“1915(b)Medi-CalSpecialtyMentalHealthServicesWaiver,”website,http://www.dhcs.ca.gov/services/MH/Pages/1915(b)_Medi-cal_Specialty_Mental_Health_Waiver.aspx42CaliforniaDepartmentofHealthCareServices,“Medi-CalManagedCarePerformanceDashboard,”website,http://www.dhcs.ca.gov/services/Pages/MngdCarePerformDashboard.aspx43CenterforHealthCareStrategies.IntegratingBehavioralHealthintoMedicaidManagedCare:Designand

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Furthermore,MMCPsandcountyMHPsmustundertakePIPsaspartoftheirqualityimprovementstrategies.DHCScouldencouragespecificPIPsbyplansandmakementalhealthintegrationthefocusandprovidetoolkitsforundertakingthem.44Forexample,CMSdevelopedPIPToolkitsforimprovingchildren’soralhealthaspartofanationalOralHealthInitiative.45

DHCScouldusetheseasamodeltodeveloptoolkitsfocusedonintegrationandsharedqualityimprovementbetweenmanagedcareandcountySMHplans.

6.2.8LeverageNewMedicaidManagedCareRegulationstoPromoteReformAsnotedearlier,MHPsareclassifiedasPrepaidInpatientHealthPlans(PIHP)andalreadymustcomplywithasubsetofMedicaidmanagedcarerules(theirnon-riskpaymentmodelexemptsthemfromotherrules).CMSclearlyarticulateditscomplianceexpectationsinthelast1915(b)waiverrenewalbyrequiringMHPstomeetandmonitorstandardsfortimelyavailabilityofservices.ThenewMedicaidmanagedcarerulespresentopportunitiestoapproachbehavioralhealthqualitymorecomprehensivelyandincreaseplans‘accountability.MHP’sexemptionfromspecificrulesmayendsincethenewfinalrulesunifyrequirementsforalltypesofmanagedcareplans,includingPIHPs.46Severalnewruleshavethepotentialtoimprovetheavailabilityandcoordinationofbehavioralhealthservices.Theserequirementsincludenetworkadequacy,continuityofcareforbeneficiarieswith“specialhealthcareneeds”,andqualitymeasurementandimprovement.Fornetworkadequacy,statesmustestablishtimeanddistancestandardsformanyproviders,particularlyadultandpediatricbehavioralhealthproviders(includingSUDSproviders).47DHCShasproposednon-physicianmentalhealthandSUDSnetworkadequacystandardsthatwould

ImplementationLessonsfromStateInnovators.April2016.http://www.chcs.org/resource/integrating-behavioral-health-into-medicaid-managed-care-design-and-implementation-lessons-from-state-innovators/?utm_source=Integrating+Behavioral+Health+into+Medicaid+Managed+Care&utm_campaign=PH-BH+Brief+4-14-16&utm_medium=email.44The20151915(b)waiverSpecialTerms&ConditionsrequiresaPIPforMHPsthatcannotestablishabaselinemeasurefortimelinessofcare.ThisPIPrequirementwouldcompetewithPIPsfocusedonimprovingintegration. 45TheCenterforHealthCareStrategies,underthedirectionofMathematicaPolicyResearch,developedthetoolkitsavailablehere:https://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/downloads/pip-manual-for-states.pdfandhttps://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/downloads/pip-template.zip46FederalRegister,“MedicaidandChildren’sHealthInsuranceProgramPrograms:MedicaidManagedCare,CHIPDeliveredinManagedCare,andRevisionsRelatedtoThirdPartyLiability,”https://www.federalregister.gov/documents/2016/05/06/2016-09581/medicaid-and-childrens-health-insurance-program-chip-programs-medicaid-managed-care-chip-delivered47CodeofFederalRegulations,“Availabilityofservices,”Title42,section 438.206,https://www.law.cornell.edu/cfr/text/42/438.206

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takeeffectstartingintheJuly1,2018plancontractyear.Therearebothtimeanddistanceandtimelyaccessstandardsthatwouldvarybasedoncountypopulationsize.48Otherregulationsrequiremanagedcareplans,includingMMCPsandPIHPs,tocoordinatecarebydevelopingtreatmentplansforenrolleeswhorequirelong-termsupportsandservicesorhavespecialhealthcareneeds.49Therulesleavetostates’discretionwhetherSMIpatientsaredesignatedashavingspecialhealthcareneeds.Finally,therulesrequirequalityassessmentandimprovement,alongwithexternalqualityreview.ThestatemustdevelopandimplementaqualityplanbyMay2019.

6.2.9ExpandUseofTele-PsychiatrytoAddressWorkforceShortage

InmanyruralandCentralValleycountiesinparticular,asevereworkforceshortageofmentalhealthprofessionals(particularlypsychiatrists)exacerbatesthechallengeofprovidingacontinuumofmentalhealthservices.Insomecounties,themanagedcareplanorbehavioralhealthmanagedcareorganizationhasbeenunabletodevelopanadequatenetworktoprovidemild-to-moderatementalhealthservices.Insomeinstances,thecountymayuseothercountyresourcestoprovidemild-to-moderatecarethatthemanagedcareplanisnotprovidingduetoworkforceshortage.Expandeduseoftele-psychiatrycouldhelptoaddressthisworkforceshortage.

6.2.10EncourageHealthPlansandCountiestoShareProviders

Inmostcounties,theMHPandMMCPprovidersareseparatenetworks.If,however,providerscouldbeencouragedtoseepatientsinboththehealthplannetworkandthecountyspecialtymentalhealthplannetworks,apatientthatneededtomovebetweentheMMCPandtheMHPcouldstaywiththesameprovider.Whilesuchanapproachwouldimprovecontinuityofcareforpatients,sharingproviderswouldalsoresultinbillingandadministrativecomplicationsforproviders.Inareaswithaworkforceshortage,bothplansandcountiesmayresistsharingprovidersbecausetheyfeelprotectiveoverscarceresourcesnecessarytomeettheneedsofpatientsforwhichtheyareseparatelyresponsible.IntervieweesfromMMCPsandMHPsalsoexpressedconcernaboutcompetingforworkforcewiththeratestheycanpay.Inspiteoftheseconstraints,providersharinghasthepotentialtoimprovecarecoordinationandcontinuityofcare.

48 DepartmentofHealthCareServices.MedicaidManagedCareFinalRule:NetworkAdequacyProposal.February2017.http://www.dhcs.ca.gov/services/Documents/NetworkAdequacy_SAC.pdf 49CodeofFederalRegulations,“Accessibilityconsiderations,”Title42,section 438.206(c)(3)

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6.3SolutionsforPartialIntegrationWhileasuccessful,fullintegrationofservicesforbothphysicalandmentalhealthisalong-termgoal,someinterimsolutionsaimedatpartialintegrationneverthelesshavethepotentialtoimprovepatientcareandoutcomesintheshorterterm.Severalsuch“partialintegration”solutionsarediscussedbelow.Whileevenpartialintegrationisprobablynotentirelyachievablebefore2020,muchoftheconceptualgroundworkandkeyoperationalaspectscouldbeworkedoutoverthenexttwoorthreeyears.Furthermore,thisconceptualgroundworkwouldidentifypolicyandregulatorydetailsofpartialintegrationthatwouldhavetobe“blessed”bytheexecutiveandlegislativebranchesandincludedinthenext1915(b)waiverrenewalapplication.Partialintegrationsolutionsmaylookincreasinglyattractivetothestate,MMCPsandMHPsasameanstocomplywiththenewMedicaidmanagedcarerules.AndwhiletheMedicaidhorizonremainsmurky,reformsfromWashingtonwillverylikelyreduceavailablefederalfundsandpressstatestopursuemorevalue-basedstrategies,includingcarecoordinationandbettercaremanagement.

6.3.1IntegrateFinancialRisk

OnepotentialsolutionadvancingfullintegrationwouldbetodeveloppilotsininterestedcountieswhereinMMCPswouldassumefinancialresponsibilityforthefullrangeofmentalhealthservices(mildtosevere).Althoughmorethanoneapproachtosuchpilotscouldbedeveloped,theideawouldbeforcountiestocontractwithMMCPstoassumefinancialandcareresponsibilityfortheservicescountiescurrentlydeliver,usingthesamefundingsources(e.g.realignmentandMHSAfunds).ThisscenariowouldnotrequireregulatoryorlegislativechangesifcountiesvoluntarilycontractfinancialriskformentalhealthservicestoMMCPs.MMCPscould,inturn,contractbackwithcountiesandotherexistingprovidersforservices,atleastasaninterimsteptominimizedisruptionstopatientcare.50Underthisscenario,theprovidersremainthesamebutthefinancialriskmanagementoccurswithonepayer.Thisconsolidatedfinancialmanagementwouldimprovetheincentivestoprovideearlyinterventionandcoordinatepatientcare,bothacrossthemildtoseverecontinuumandbetweenmentalandphysicalhealth.Asaresultoftheimprovedpatientcareandalignmentofincentives,costsforthesystemwouldpotentiallydecrease.Thesesavingscouldbesharedjointlybycountiesandhealthplans,orreinvestedinprovidingenhancedlevelsofpatientcare.Forsuchaplantowork,severalimportantelementswouldneedtobeputinplace.First,giventheinstitutionalobstaclesandtheuncertaintyassociatedwithsuchachange,countiesandplanswouldlikelyneedaninitialfinancialincentivetopursuereformandtocoverthecostsofmanagingthetransition.Thesefundscouldcomefromfoundationsupportor,potentially,fromstateMHSAfunds.50Thismaybeeasierincountiesthatalreadycontractoutmanyoftheirbehavioralhealthservices.

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Second,countiesandplanswouldneedtoenterintoacontractspecifyingrespectiveplans’responsibilities,paymentmechanisms,reporting,andotherrequirements.Thiscontractingwouldincludespecificmeasuresofpatientcare,carecoordinationandcontinuity,andfinancialmetricsassessingoverallcosts.Countiesandplansmightbenefitfromassistanceindevelopingmodelcontracts,reportingmechanisms,andotherrequirements.ImplementationofsuchasharedresponsibilitymodelcouldbebasedonsuccessfulaspectsoftheCoordinatedCareInitiative(DualsDemonstrationproject).51Underthismodel,themanagedcareplanprovidesthefullcontinuumofphysicalandbehavioralhealthservicesthroughacapitatedrate.52ThisarrangementisgovernedbyaMOUthatdetailsspecificperformancemetrics.Underthetermsofthepilot,DHCSwillwithholdaportionofcapitatedpaymentsfrommanagedcareplansuntilplansmeetspecifiedperformancemetrics,withsavingsexpectedtoaccruefromexpectedsavingsduetopreventablehospitalizations.53ThisexampleofsharedaccountabilitycouldbeadaptedtoacountyMHP-MMCPjointeffortsuchthatcountieswouldwithholdapercentageofthecapitatedrateuntilMMCPsmeetperformancemetrics,withcountiesreceivingapercentageofsavingsifcostsamounttolessthantheprescribedrate.Convertingmultiplefundingstreamsintoacapitationratecanbechallenging,butmanagedcareplanshavedonesotoincludebehavioralhealthservices(e.g.ValueOptionsMarylandandColoradoBehavioralHealthOrganization).54Challenges-Whilethismodelhassomepromiseasameansofaddressingtheproblemsassociatedwithabifurcatedsystemofdeliveringcare,someintervieweesexpressedconcerns.Forexample,someintervieweesbelievethatMMCPsareadequatelyexperiencedinaddressingthelocalpoliticsthatmightbenecessaryforongoingnegotiationsoverthefinancial

51WhiletheCoordinatedCareInitiativeisformallydiscontinuedinthe2017-2018budget,theAdministrationproposedcontinuingprogrammaticcomponentsofthedemonstrationaimedatreducingcostsandimprovinghealthoutcomes.52InadditiontoSMHPservices,MedicarePartDandDrugMedi-Calarealsoexcludedfromthecapitatedrate.53CaliforniaDepartmentofHealthCareServices,“DualsDemonstrationMemorandumofUnderstanding,”webpage,http://www.dhcs.ca.gov/Pages/demoMOU.aspx;CaliforniaDepartmentofHealthCareServices,“CoordinatedCareInitiative:EvaluationOutcomeReport,”http://www.dhcs.ca.gov/formsandpubs/Documents/Legislative%20Reports/CCI_Outcomes-Evaluation_April2016.pdf;“MemorandumofUnderstanding(MOU)betweenTheCentersforMedicareandMedicaidServices(CMS)andTheStateofCalifornia,”https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/CAMOU.pdf;“TemplateLanguageformemorandumofUnderstandingbetweenDualsDemonstrationHealthPlansandCountyBehavioralHealthDepartments,”http://www.calduals.org/wp-content/uploads/2013/02/Local-BH-MOU-Template-02-15-13.pdf;ExampleMOUinLACounty:http://lacdmh.lacounty.gov/News/Board_Correspondence/Adopted_Board_Letters/Adopted%20BL_DMH_PH_PSS_MOU%20with%20Health%20Net%20and%20LA%20Care_081313.pdf54NationalCouncilforBehavioralHealth.2014.“EnsuringAccesstoBehavioralHealthcarethroughIntegratedManagedCare:OptionsandRequirements,”http://www.thenationalcouncil.org/wp-content/uploads/2014/11/14_Managed-Care-2.pdf

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arrangements.Inothercases,intervieweesexpressedreservationsaboutMMCP’sabilitytoprovidehighqualitymentalhealthservices,regardlessoffinancialincentives.Further,thetraditionalmedicalmodelmaynotadequatelymeettheneedsoftheSMIpopulation,andsomedoubttheabilityofMMCPstoembracearecoverymodel.Finally,someexpressedconcernthattheregulatorycomplianceoftheMMCPswouldcreateanevengreateradministrativeburdenthanthecountycurrentlyexperiences.

Inspiteofthepotentialobstacles,pursuingapilotincarefullyselectedcountieswithwillingandcapablepartnersonbothsidescouldhelpbuildacaseforadditionalpilotcommunitiesandeventuallybroaderintegrationacrossthestate.

6.3.2CountyMHPsAssumeFullResponsibilityforMild,Moderate,andSevereMentalHealthServices

Analternativetofullintegration(whetheronapilotorstatewidebasis)isascenariowhereincountiesassumeresponsibilityforpatientsneedingmild,moderateorseverementalillnessservices.Theadvantagesofthisscenarioincludeleveragingdecadesofinvestmentincountymentalhealthservicesandseamlessprovisionofservicesalongthementalhealthcarecontinuum.Suchanapproachnotonlyhasthepotentialtofillgapsincare,butitwouldalignfinancialincentivesforearlyintervention,provisionoffollow-upcareaftercrisis,andeliminationofpayerdisputeandconfusion.Insomecountieswithparticularlywell-developedmentalhealthsystemsandintegrationofcountyservices(e.g.CountyOrganizationHealthSystemcounties),thisapproachmayalsobeworthexploringwithsharedaccountabilitycontractsforcarecoordinationlikeCalMediConnect(seesection“Integratefinancialrisk”).MMCPscouldsubcontractmild-to-moderateservicestoMHPsinsteadoftoaMBHOasmanycurrentlydowithoutlegislativeorregulatorychanges.CircumventingMMCPsentirelywouldrequireachangeinstatuteandfinancingmechanisms.Challenges-Asignificantlimitationinthisapproachisthecontinuedbifurcationofhealthcareandmentalhealthservices.Whilementalhealthservices–thoughlikelynotSUDS–wouldbeintegratedandmanagedinasinglesystem,patientsphysicalhealthneedswouldbemetbyseparateMMCPs.

6.3.3CountyMHPsAssumeFullResponsibilityforAllServicesforSMIpopulationAsdescribedearlier,oneofthechallengesconfrontingSMIpatientsistheseparationbetweenphysicalandmentalhealthproviders.ThischallengecouldbeaddressedbycreatingasysteminwhichcountiesassumetheresponsibilityforphysicalhealthcareaswellasmentalhealthcarefortheSMIpopulation.Inthisscenario,thePMPMforphysicalhealthforthispopulationwouldbepassedthroughfromMMCPstoMHPs.CountieswouldthencontractwithhospitalsandotherhealthcareprovidersforprovisionofphysicalhealthcareservicesfortheSMIpopulation.

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ThiswouldmakeiteasiertoprovidewholepersoncaretotheSMIpopulationbyjoiningthefullfinancialriskwiththeknowledgebaseofMHPs.ThisscenariowouldworkbestincountieswhereMHPsalreadyhavestrongrelationshipswithFQHCsandphysiciannetworks,awell-developedcountyclinicnetwork,oracountyorganizedhealthsystemwithacountyhospital.Challenges–Whilethisapproachwouldbetterintegratehealthandmentalhealthservicesunderonesystem,itreinforcesthesegregationofSMIpatientsintocountySMPs.ThiscouldhavetheconsequenceoffurtherstigmatizingthispopulationandcomplicateanytransitionsbacktoMMCPsshouldthemodelnotwork.

6.4Longer-termChange:FullIntegrationbyEndingthe“CarveOut”

Themosteffectivewaytoaddresstheproblemsofsiloedcareistoconsolidatetheresponsibilityfordeliveringthefullrangeofmentalhealthservices,frommildtosevere,withinasingleentity.Suchanapproachwouldalignincentivessuchthattheentitypayingformentalhealthserviceswasencouragedtoprovidethebestservicesatthelowestcost,includingearlyinterventionandcarecoordinationthatwouldreducelong-termcostsandimprovepatientoutcomes.Themostambitiousandeffectivesolutionwouldbetointegratephysicalhealth,mildandmoderatementalhealth,specialtymentalhealthunderasingleentity,presumablyMMCPs.55Withasingleentityresponsibleforallpatientcareneeds,incentivesinthesystemwouldencourageinvestmentsinearlyinterventiontoavoidmoreexpensivecrisesinthefuture,carecoordinationtomakesurethatpatientsreceivedthecaretheyneededandfollowedthroughonreferralsandtreatmentplans,andseamlessexchangesofinformationamongapatient’smanyprovidersacrossnetworks.StrongcontractswouldbenecessarytosupporttheinfluenceoffinancialincentivesonMMCPprovisionofqualitybehavioralhealthservices.56A2014paperbytheNationalCouncilforBehavioralHealth,“EnsuringAccesstoBehavioralHealthcarethroughIntegratedManagedCare:OptionsandRequirements,”emphasizestheneedforextensivemeasurementofaccessandqualityofcare,especiallyforbeneficiarieswithSMI.StateswithsuchstrongcontractsincludeKansasandTexas.57Kansastiedfinancialincentivestoperformancemetricsthatinclude

55Forexample,thestateofWashingtoniscurrentlyintegratingallhealthcareservicesunderitsMedicaidmanagedcareplans.56SeveralintervieweesarguedthatrelianceonfinancialincentiveswouldbeinsufficienttoensurequalitycoverageofbehavioralhealthservicesbyMMCPsOthersexpressedskepticismthatthefinancialincentivesofpopulationhealthmanagementwouldprovidesufficientqualityassuranceforbehavioralhealthcare,particularlyfortheSMIpopulation.Seesection,“ManagedCarePlanandProviderOrganizationalandCulturalChangetoIntegrateBehavioralHealth,”fordiscussionofhowMMCPswouldneedtochangepracticestoprovidequalitycareforSMI.57CenterforhealthCareStrategies,Inc.2016.“IntegratingBehavioralHealthintoMedicaidManagedCare:LessonsfromStateInnovators,”http://www.chcs.org/resource/integrating-behavioral-health-into-medicaid-managed-care-design-and-implementation-lessons-from-state-

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fivemeasuresforSUDandeightmeasuresformentalhealth(e.g.increasedaccesstoservices,improvementinhousingstatusofhomelessSMI,anddecreasedutilizationofinpatientpsychiatricservices).58TheNationalCouncilforBehavioralHealthpaperalsooutlinesoptimalplandesignsforMMCPstotakeonbehavioralhealthservices.Forexample,aplanshouldidentifyindividualswithSMI,SED,orseriousSUDandtracktheircare.ThestateshouldsethighercapitationratestoaccountforthehigherexpenseofthesecasestopreventMMCPfromdiscouragingtheirenrollment.And,statesshouldrequireservicesprovidedinarecoverymodel,thoughsomeservicesmaybeexcludedfromthecapitationrateandprovidedbybraidingotherfundingstreams.59MorechallengingthandesigningastrongcontractandreorientingMMCPstowardarecoverymodelforbeneficiarieswithSMIaretheinstitutionalobstacles.IntegratingallMedi-CalhealthcareservicesinCaliforniawouldbeaHerculeantaskandwouldlikelyrequireaballotinitiative,legislativeandregulatoryactions,CMSapproval,andactionsbyBoardsofSupervisors,allofwhichposepoliticalandadministrativechallenges.First,sucha“fullintegration”policywouldrequirechangestoboththe1991and2011realignmentstotransferfiscalcontrolformentalhealthservicesbacktothestate.60Second,legislationwouldberequiredtoassignresponsibilityforallmentalhealthbenefitstoMedi-Calmanagedcareplans.Third,suchachangeinbenefitsandmanagedcarerequirementswouldnecessitateseveralothercontractualandregulatorychanges.ThestatewouldhavetosubmitanamendmenttoitsMedicaidStatePlanforapprovalbyCMS.61Underthisfullintegrationscenario,DHCSwouldamenditsMedi-Calmanagedcarecontracts,determineactuariallyfairratesfortheadditionalbenefits,andassurethatplansmeetnetworkadequacyfortheentirespectrumofmentalhealthservices.Finally,afullintegrationplanwouldrequireDHCStorequestfromCMSachangetothe1915(b)SpecialtyMentalHealthWaiverthatcurrentlycarvesoutspecialtymentalhealthtothecountyMHPs.Althoughthesechangesaresubstantial,theywouldnotnecessarilyresultinincreasedstatecoststotheextentcurrentservicelevelsaremaintained.Infact,inthelongrun,itislikelythat

innovators/?utm_source=Integrating+Behavioral+Health+into+Medicaid+Managed+Care&utm_campaign=PH-BH+Brief+4-14-16&utm_medium=email58KansasDepartmentofHealthandEnvironment,DivisionofHealthCareFinance.2015.“KanCareFinalEvaluationDesign,”March.http://www.kancare.ks.gov/download/KanCare_Final_Evaluation_Design_Revised_March_2015.pdf59NationalCouncilforBehavioralHealth.2014.“EnsuringAccesstoBehavioralHealthcarethroughIntegratedManagedCare:OptionsandRequirements,”http://www.thenationalcouncil.org/wp-content/uploads/2014/11/14_Managed-Care-2.pdf60“AComplexCase:PublicMentalHealthDeliveryandFinancinginCalifornia,”CaliforniaHealthCareFoundation,2013,http://www.chcf.org/publications/2013/07/complex-case-mental-health61California’sStateMedicaidPlan(TitleXIX).http://www.dhcs.ca.gov/formsandpubs/laws/pages/californistateplan.aspx

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costswouldbereducedasaresultofinvestmentsinearlyinterventionandprevention.Inthenear-term,utilizationratesforphysicalhealthservicesfortheSMIpopulationcouldincreaseasaresultofincreasedaccesstocare,buttheseincreaseswouldlikelybeoffsetbylong-termsavingsasaresultofavoidedhospitalizationsandreducedemergencydepartmentuse.Inspiteofthelargepotentialbenefits,challengesinaddressingtheorganizationalinertiaandpoliticalresistancefromcountiesalongwithdecadesofpolicy-makingaroundrealignmentmeanthatfullsystemicintegrationisaverychallengingscenario,atleastinthenear-term.

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AppendixA:CurrentDataCollectionandReportingEfforts

Currentdatacollectionandmonitoringeffortscanbeleveragedtopursuethetypeofinformationneededtostimulatereformefforts.EvaluationsoftheDrugMedi-Calpilot62,theHealthHomeInitiative,andWholePersonCare63willlikelyyieldinformationoncontinuityofcare,carecoordination,andchallengesunaddressedbythepilots.SincethesepilotsdonotextendstatewideanddonottestchangesintheunderlyingbifurcatedstructurethatdisruptsdeliveryofthefullcontinuumofmentalhealthservicesandphysicalhealthcareforindividualswithSMI,additionaldatacollectioncouldilluminatetheneedforintegrationatthepayerlevel.

MoststatewideeffortstocollectdataanddeveloppublicdashboardsfocusonthequalityofservicesseparatelyprovidedbyMHPsandMMCPs.AresourceforSMHPutilizationdataforchildrenandyouthispublicallyavailable.TheDHCSReportsandMeasuresCatalogprovidesPerformanceOutcomeSystemReportsforchildrenandyouthinthecountySpecialtyMentalHealthPlansystem.64ThemeasuresweredevelopedthroughastakeholderprocessasrequiredbytheWelfareandInstitutions(W&I)CodeSection14707.5forEPSDTmentalhealthservices.65Themeasuresincludepenetrationrates,definedasthenumberofyouththatreceivedatleastonespecialtymentalhealthservicedividedbythetotalnumberofyouthMedi-Calbeneficiaries.Penetrationratesarestratifiedbydemographiccharacteristics.Theutilizationdatafurtherdescribechildrenarriving,exiting,andcontinuingservicesina2yearperiodandthetimetonextSMHPcontactafterinpatientdischarge.66DHCSprovidesthesedataatthestateandcountylevel.AnotherPerformanceOutcomeSystemReportaggregatesConsumerPerceptionSurveysforyouthorfamilymembersofyouthages13-17andlimitsreportingtothestatelevel.67

62CaliforniaDrugMedi-CalOrganizedDeliverySystem:ProposedEvaluation.UCLAIntegratedSubstanceAbusePrograms.June2016.http://www.uclaisap.org/ca-policy/assets/documents/DMC-ODS-evaluation-plan-Approved.pdf63CaliforniaDepartmentofHealthCareServices.WholePersonCareEvaluationDesign.November2016.http://www.dhcs.ca.gov/provgovpart/Documents/WPCDraftEvalDesign.pdf64“ReportsandMeasuresCatalog,”DHCSwebsites,http://www.dhcs.ca.gov/provgovpart/pos/Pages/Performance-Outcomes-System-Reports-and-Measures-Catalog.aspx65“LegislativeReport:PerformanceOutcomesSystemPlanforMedi-CalSpecialtyMentalHealthServicesforChildrenandYouth,”May2015,SubmittedbytheDepartmentofHealthCareServices,http://www.dhcs.ca.gov/individuals/Documents/POS_LegReport_05_15.pdf66http://www.dhcs.ca.gov/services/MH/Documents/POS_StatewideAggRep_Sept2016.pdf67“PerformanceOutcomesSystemInitialReports,”ReportRunonAugust11,2015,http://www.dhcs.ca.gov/services/MH/Documents/20160412_POS_CPSReports.pdf

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TheSpecialTermsandConditionsfromthe1915(b)waiverrequiresDHCStopostSMHPperformancedataonquality,access,andtimeliness.68TheMedi-CalSpecialtyMentalHealthServices(SMHS)PerformanceDashboardsprovidesummarydataonkeyperformancemeasuresofCountyMentalHealthPlans(MHPs),individuallyandstatewide.Eachdashboardincludesinformationinthefollowingdomains:quality,access,andtimelinessofSMHS,aswellasinformationabouttheMHP'stranslationandinterpretationcapabilitiesandutilizationdata.Currentlythedashboardsareavailableforchildrenandadultsataggregatedatthestatewidelevel.Countyreportsarenotyetavailable.

68“Medi-CalSpecialtyMentalHealthServicesPerformanceDashboards,”DHCSwebsite,http://www.dhcs.ca.gov/services/MH/Pages/SMHS_Performance_Dashboard.aspx