This is an exclusive BHB+ article.
There are few issues these days that payers, providers and even the government can agree on. That’s what makes integrated care so remarkable – but also what makes the slow progress so frustrating.
An imperfect payment system and confusion around who is acting as the quarterback in a patient’s care journey have made implementation difficult.
Earlier this week, I traveled to Washington, D.C., to sit down with some of the movers and shakers in the integration movement at The Association for Behavioral Health and Wellness (ABHW)’s annual conference.
One of the best parts of my job is picking the brains of leaders in the space to find out what the public is missing on issues. And what I found out is although this issue seems like a simple win win for payers and providers, integration is operationally complicated.
But if done well, integrated care can lead to serious cost reductions, not to mention better health outcomes. A 2021 study published in Medical Care, found collaborative care was associated with substantial cost savings of roughly $1.70 for every dollar spent on implementation.
Yet, with so many stakeholders involved, it’s hard for one party to step up and foot the implementation bill.
“If none of us as providers are responsible for the total cost of care for that patient in front of us, it’s really hard to make the argument to implement these models,” Dr. Caroline Carney, CEO of Magellan Health, said on a panel I moderated.
In this BHB+ Update, I will explore:
– What is standing in the way of integrated care
– What models could work for integrated care
– Where alternative payments fit into integrated care
Alternative payment models enabling integrated care
Because the bulk of dollars saved with integrated care tends to be on the physical health side, it can be a hard sell for providers.
Mike Rhoades, CEO of Alera Health, a company focused on helping providers build integrated care systems, noted that while his team has seen some reduction in inpatient psychiatric stays from implementing integrated care, the bulk of cost savings is in less emergency department visits and even med surg.
Despite the cost reduction, there are still questions about how these types of integration programs get financed.
“Fee-for-service models aren’t it. We probably need more capitated, integrated funding streams,” Chuck Ingoglia, CEO of National Council of Mental Wellbeing,
said at the event. “We’ve had experiments like health homes in Medicaid. … [That’s] a great starting point, … but we need explicit, integrated, longitudinal funding.”
The National Council of Mental Wellbeing is a nonprofit organization that advocates for high-quality services. Its members are mental health and substance use treatment organizations.
It’s not just behavioral health providers that are interested in shared savings. Without alternative payment models, carve-out behavioral health payers are paying for additional services, while the physical health payers see the benefits.
“A lot of the outcomes and benefits accrue to someone else,” Arthur Evans, CEO of the American Psychological Association, said on the panel. “Especially as a behavioral payer, you saw a lot of the benefit accrue to the physical health side, and we really have to look at alternative payment models that incent people to practice in this way so that the cost of the savings and benefits are shared.”
The American Psychological Association is an industry group representing psychologists in the U.S.
In order for alternative payments to support these kinds of services, there needs to be technology in place to guide these integrated care efforts and prove outcomes – a tricky proposition in an industry where a good portion of providers are still working off paper records.
”How does the data flow so that you’re making smart decisions about how you’re deploying resources?” Ingoglia said. “I think a lot of the time right now organizations are shooting in the dark and hoping that their intervention is going to make a difference or they are targeting the right people without the right data.”
The transition to paying for these integration services comes at a pivotal time in the nation, as Medicaid redeterminations and work requirements in the One Big Beautiful Bill will likely impact young and healthier people. That will leave a higher proportion of patients with serious mental illness (SMI), disabled and polychronic conditions.
“We’re going from 36% concurrence of behavioral health to 48% to 52%,” Ingoglia said. “Are we in the managed medical care business anymore or are we in the managed behavioral health business?”
The operational hurdles
While in theory integrated care is the gold standard, the operational challenges on a day-to-day basis cannot be understated.
Carney gave the example of the Federally Qualified Health Center (FQHC) that she works with in Indiana. Two of the three Medicaid plans in the region will not pay for collaborative care but the third will. This creates confusion for the front desk and the billing department.
“There’s confusion like that that prevents this model from really moving forward in a way that it could or should,” Carney said. “The other biggest barrier I’ve seen from my health plan perspective is that as a health plan, I go to a clinic that is working with multiple health plans and they can’t sort their members coming in day after day by health plan and then determine which patients can have collaborative care.”
Others echoed similar sentiments.
“I’m a strong proponent of integrated care but I do think it’s important to understand that integrated care is only a means to an end,” Evans said. “If our focus is on getting integrated care, we might lose [sight] of the real purpose, which is to improve access and outcomes for people.”
He noted that integrated care needs to be flexible and may look different for each population.
For example, he noted that when he was commissioner of Philadelphia’s Department of Behavioral Health and Intellectual Disability Services, there were certain immigrant groups that often struggled to access physical health care, and behavioral health care was not a top concern. Thus, integrating behavioral health into a physical care setting would make the most sense.
“It was a real critical issue to ensure that they had access to embed services in the place that they would go [for services],” Evans. “For other populations, like people with serious mental illness, they have a strong connection to their behavioral health provider. So when I think about integrating care for them, I’m not thinking about primary care; that’s not where they are connected to. So the issue there is how do we integrate primary care into the settings they are already going to?”
From an operations lens, there is likely no one-size-fits all in who is the quarterback of care. It truly depends on the patient. And this type of arrangement could be beneficial in many places from an OB’s office to an oncologist’s office.
Still, a lot of these efforts are aspirational. So I asked speakers what is the No.1 priority you would ask for if you had a direct line to federal regulators.
“I would say that Medicaid health plans, and the states don’t get a choice, they have to pay for behavioral health integration in some way, shape or form, and they have to run on the collaborative care codes no matter what. It’s just something that needs to be done,” Carney said.