Demand for behavioral health services is high, but people often struggle to find help. The problem is particularly acute for Medicaid beneficiaries given what are typically more limited provider networks.
As part of broader efforts to strengthen primary care, Rocky Mountain Health Plan in Colorado’s Western Slope has increased access for Medicaid beneficiaries by paying primary care providers substantially more to hire behavioral health staff and offer routine screenings, brief interventions, ongoing therapy for mild to moderate conditions, and warm handoffs to therapists and other specialists. Its alternative payment model has increased reimbursements for primary care providers while lowering overall spending.
We spoke to Patrick Gordon, CEO of Rocky Mountain Health Plan, about the benefits of the program for patients, providers and payers.
Why did Rocky Mountain Health Plan focus on integrating behavioral health into primary care?
Gordon: Behavioral health historically has been something done by somebody else, somewhere else: specialized organizations, specialized networks, specialized programs, specialized financing. But in recent years, integration has become a priority for states — and for consumers. People are increasingly expecting ready access to behavioral health services. Primary care is an excellent entry point. It's where most people use services. It's where most prescriptions are written. It's where relationships can be established. And it's also the most proactive segment of the healthcare system. When we looked at it through that lens, it really simplified our approach.
When you started back in 2014, what were the biggest needs among your Medicaid members?
Gordon: We knew things like depression and anxiety were significantly underdiagnosed. And we knew there were barriers to screening because providers were concerned if they identified a need, where were their patients going to go? Addressing these two basic needs are at the foundation of the work we are doing today.
How have you partnered with practices to help them build capacity to offer behavioral health services?
Gordon: First, we offered practices upfront funds to hire licensed clinical social workers and psychologists. In the early years, we ran learning collaboratives. We brought in national experts but, most importantly, we brought local clinical leaders together to learn from each other. We also put coaches on the ground to offer technical assistance for things like how to screen for mental health and substance use disorders and how to adjust clinical workflows to respond to identified needs. We moved forward with complete transparency. We eventually got to a place where it was pretty clear what was required of practices and what they could count on from us in return.
How do you assess whether this approach is helping patients?
Gordon: It’s challenging because patients who may have behavioral or emotional needs may characterize those as physical needs. They may say things like, “I feel sick to my stomach. I can't sleep.” They don’t say to their doctor, “I've got anxiety. Maybe I'm drinking too much. I don't have enough food to eat.” But we do have performance data demonstrating that providers’ ability to serve populations with complex emotional, social and physical needs has grown. They're serving more patients with complicated needs than they were before, and they're more willing to engage in a broader array of assessment and referral activities, particularly social determinant risk factor screening. And that's very telling.
What advice would you offer other health plan leaders about integrating behavioral health services?
Gordon: Just start. Don’t spend the next three years in analysis paralysis. And don't just center on behavioral health integration. A comprehensive strategy to develop practice competencies in team-based care, patient empanelment and stratification, care coordination, data use and quality improvement is also essential, all of which entail new payment, data, reporting and coaching workforce commitments on the part of the plan. We look at how our investments are playing out, we look at the ability of our primary care partners to drive whole-person health, not just the behavioral health component. And we look at clinician experience. Is there a lower turnover rate? Are they able to focus on the highest-value services because of the resources available to them?
I also think it’s important to give providers flexibility at the outset. We're not overly prescriptive about how the practices use the resources we make available, other than ensuring they have a minimum number of staff and they achieve quality targets. But we do invest in surveys and other tools that enable ongoing, robust dialogue so that we’re receiving “human intelligence” in addition to business intelligence. Qualitative feedback from practices and from patients is invaluable.
About the authors
Martha Hostetter and Sarah Klein produce the Commonwealth Fund's Transforming Care publication series, which explores the people and places reinventing healthcare.
The Commonwealth Fund is a nonprofit foundation supporting independent research on healthcare issues and making grants to promote better access, improved quality and greater efficiency in healthcare, particularly for society’s most vulnerable, including people of color, people with low income, and those who are uninsured.