Integrating Behavioral Health: Lessons Learned in Washington State

Sept. 23, 2020
Under Washington’s new fully integrated system, managed care organizations coordinate care across the full continuum of physical and behavioral health services

In most states, the care delivery systems for physical health, mental health, and substance use disorder services are siloed and unable to share information across systems, leading to fragmented care. Although the transition is challenging, Washington state is seeing some positive early outcomes from its shift to physical-behavioral health integration.

Medicaid spending is four times higher for individuals with behavioral health conditions, largely due to increased physical health spending, and many experience gaps in care due to poor coordination and information sharing between providers In a Sept. 22 webinar put on by the nonprofit Center for Health Care Strategies and co-sponsored by the California Health Care Foundation, leaders from Washington state described some of the lessons learned in creating a one-payer system accountable for whole-person care.

Teresa Claycamp, a licensed mental health counselor who serves as the integrated managed care program manager for the Washington State Health Care Authority, said that before the work began several years ago, Washington had a very fragmented system with some services administered at the county level and others at the state level. There was no single entity with accountability, nor with the data and information necessary to manage the whole person, she noted. Consumers with co-occurring disorders were navigating disparate systems with no single point of contact. Under that system, care coordination is duplicated, and bi-furcated funding streams make it challenging for providers to move to integrated care models.

State legislation passed in 2014 changed how the state purchases mental health and substance use disorder services in the Medicaid program. It directed the state to fully integrate the financing and delivery of physical health, mental health and substance use disorder services in the Medicaid program via managed care by 2020. As a white paper from the Center for Health Care Strategies explains, “under the fully integrated managed care system, managed care organizations (MCOs) coordinate care across the full continuum of physical and behavioral health services. Each region contracts with between three and five MCOs, chosen from a competitive bidding process among the existing Medicaid MCOs.”

Under the integrated model, one MCO is accountable for keeping people healthy, both mind and body. Individuals have one point of contact for questions and one dare coordinator. Over time, providers and MCOs can work together to establish new payment methodologies and integrated care models. Claycamp said one key to success has been to build some flexibility into the program. “We worked with King County to allow it to have a slightly different structure, and we did allow for some flexibility and regional nuance to allow this to be done over a four-year period.” She also said that integrating the administrative side is easier that working on clinical integration. “Just because we did administrative and financial integration doesn’t mean that there isn’t still a lot of work that needs to be done on the clinical side.”

The transition to fully integrated managed care has only been in place statewide since January 2020, the white paper noted. But preliminary evaluations suggest the state is seeing some signs of improved outcomes from the transition.  An evaluation reported improved health and social outcomes for Medicaid enrollees in the Southwest Washington region (the first region to transition) as compared to the rest of the state, during the first year after that region’s transition. “While 21 out of 29 measures did not show a statistically significant change, seven measures showed a statistically significant improvement and one showed a statistically significant relative decline,” the CHCS white paper noted.  “This region saw statistically significant improvements in most measures of access to care among all Medicaid enrollees, including access to ambulatory and preventive care and mental health treatment penetration, as well as in social outcomes such as rates of homelessness and criminal justice interactions.”

Challenges Encountered

Besides the MCOs, the state system is set up with an administrative services organization (ASO) for each region. Joe Valentine, M.S.W., executive director of the North Sound Behavioral Health Administrative Services Organization, said one challenge they ran into during this transition is that behavioral providers tend to have inadequate electronic infrastructure to submit claims and encounter data. “Behavioral health agencies do not have adequate EHRs to interact with MCOs. We got $6 million in funding to upgrade EHR systems, and even that was barely enough,” he said. “The behavioral health agencies don’t have the sophistication to select products to meet their needs, and the EHR vendors weren’t ready to take on this heavy of a lift, adding this many organizations into a new platform.”

During the early testing stages, providers had a percentage of claims rejected, which led to cash-flow problems because they are operating on slim margins to start with.  Another challenge is that because five MCOs serve their regions, those agencies needed contracts with all five MCOS, which have different billing and reporting requirements.

Another issue is that there is little pre-existing on-site integration of physical and behavioral health. “Clinical integration is really starting from scratch,” Valentine said.

On the positive side, the shift does seem to support improved access to physical health care because there is more care coordination for high-risk patients. Also, the MCOs have flexibility and can use funding for things like cell phones and food vouchers, which has been particularly valuable during the pandemic, he said. That same flexibility allows MCOs to be creative in how they provide funding to behavioral health providers to tide them over during the pandemic.

In addition, Valentine said, the NCQA standards to support quality of care are valuable. “That was foreign to behavioral health agencies before, and it has helped raise the quality of care,” he said.

Valentine recommended paying  special attention to integrating care for persons with severe behavioral health disorders. “It is one thing to integrate services in primary care for most folks. But people with severe disorders often don’t go to primary care. Sometimes they don’t feel welcome. The integration for this population requires more thought,” he said.

He also recommended developing new data exchange strategies that can follow the persons as they move between payers. One challenge is health information still being segregated into silos. A mobile crisis outreach team may not have access to treatment information and are in essence going out blind. “We are trying to look at new platforms that we and all the MCOs can share as a common platform. That is a challenge.”

Some things are going to require more investment in capacity, he said. “In our region, we have a shortage of crisis beds. Integrated care doesn’t address that. It requires an investment strategy. We have to look at creating new facilities and programs. It requires additional investment.”

King County Integrated Care Network

Isabel Jones is deputy director of the Behavioral Health and Recovery Division of King County, Washington’s largest county with 600,000 Medicaid enrollees and an overall population of 2.2 million. She described the county’s braided funding mechanism and administrative structure. 

As Claycamp mentioned, King County was granted flexibility to structure things a little differently because it had been working on integration issues longer. “We have a one-tenth of 1 percent local sales tax that brings in approximately  $80 million  per year,” Jones explained. “That local funding of the behavioral health system helped make our integrated model achievable and acceptable to partners. We are investing in the Medicaid treatment system to expand Medicaid treatment and support infrastructure.”

Their public/private model is called the King County Integrated Care Network (KCICN) , and the five MCOS have delegated many of the administrative functions to the county to manage on their behalf.  All five MCOs contract with King County to manage the KCICN network and provide access to services via this network for Medicaid members.

KCICN is a new partnership between King County Behavioral Health and Recovery Division and provider agencies to serve the Medicaid population in the King County region. There are 40 provider organizations in the network, and they are involved in the governing structure making all major decisions about behavioral health services, Jones said. “The benefit is simplification. There is one provider relation team and centralized administrative functions rather than five MCOs to deal with, “ she said. “We have been able to achieve some of the benefits of integrated care,” primarily around data sharing,  risk assessment and care coordination.

Among the lessons learned, she said it was a significant effort to meet NCQA and MCO delegation requirements. “We are operating almost like a health plan. We have NCQA requirements we need to meet,” she said. Starting from scratch it would take a year to do the work to prepare and be ready to meet the requirements.

She said the county is very much in a leadership position and able to drive progress and set a vision for new programs for physical health integration pilots. It can negotiate to move initiatives forward. “The MCOs are competitors. They are not naturally poised to come together on a joint vision,” she said. “Unless the county or state is in a leadership role, it is hard to get them to come together.”

The county is working on the use of a data-driven population health stratification tool, inclusive of social determinants of health and criminal justice system data. It also is developing value-based payment agreements across payers as well as standardized performance metrics. It wants to develop closer relationships with primary care providers and focus more on clinical integration at the service delivery level.

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