While experts long have urged better care coordination, medical and behavioral-health providers have not traditionally worked together closely. One reason for the disconnect is the fragmented fee-for-service payment model, in which primary-care and behavioral-health clinicians do not communicate or collaborate. On top of that, medical and behavioral-care providers serving Medicaid patients are often understaffed and underpaid, with little time to carry out comprehensive care plans for their challenging patients.
As a result, many Medicaid beneficiaries with serious mental illness or addiction end up in hospital emergency departments. “Before (integration), you may have had a primary-care physician who ordered a patient medication for diabetes and they might not have had any clue what that individual was taking for their behavioral-health condition,” said Nelson of the Arizona Department of Health Services. “And they wouldn't have necessarily known who to call unless that patient self-disclosed that they had a behavioral-health issue.”
That's why state Medicaid programs increasingly are developing integrated-delivery models to encourage collaboration between physical and behavioral-healthcare providers, overseen by managed-care plans paid under performance-based contracts. “Providers are being held accountable for patient outcomes, and when you're accountable for patient outcomes, either as a provider or as a health plan, you simply cannot ignore the interaction between physical health and behavioral health challenges,” said Deborah Bachrach, a partner at the law firm of Manatt, Phelps and Phillips and former Medicaid director for the state of New York.
But health plans and providers still face numerous challenges in coordinating physical and behavioral services. Medicaid's traditional fee-for-service payment model, coupled with traditionally low reimbursement rates for behavioral-health services, has worked against providers attempting to integrate their services, according to a February report from the Kaiser Commission on Medicaid and the Uninsured. Even in states that have implemented Medicaid managed-care programs, behavioral care often is carved out from medical care and delivered by separate providers through a separate payment stream, Bachrach said. “States are starting to think about how to do a more cohesive purchasing strategy,” she said.
Another barrier to service integration is a Medicaid policy that will not allow providers to be paid separately for medical care and behavioral healthcare delivered in the same patient visit. For example, if a patient receives a physical exam from a physician and counseling from a psychologist, Medicaid will not pay separately for the two services. “If you're talking about good integration and good care coordination, it becomes a barrier if a patient has to come back the next day,” said Laura Galbreath, director of integrated health solutions for the National Council for Community Behavioral Healthcare.
Federal and state privacy rules create further hurdles, restricting the sharing of patient information between medical and behavioral-health providers. Without such sharing, the risks increase for duplicated services and adverse patient outcomes, such as incompatible medication prescriptions.
Many types of inflexible rules can get in the way of coordinating care. For nearly two years, Dr. Cara Christ, chief medical officer for the Arizona Department of Health Services, worked on revising state rules to allow behavioral-care providers to deliver services at medical-care sites. “For years in Arizona, you could either be a behavioral-health institution or you could be a physical-healthcare institution,” she said. “You weren't allowed to do the same thing in the same building to the same patient.”