Making Integration Work: Key Elements for Effective Partnerships Between Physical and Behavioral Health Organizations in Medicaid FEBRUARY 2020 AUTHORS Logan Kelly, MPH and Allison Hamblin, MSPH Center for Health Care Strategies Contents The Authors 3Background Logan Kelly, MPH, is senior program officer, and 5Profiled Partnerships Allison Hamblin, MSPH, is President and CEO, of the Center for Health Care Strategies, a national nonprofit 7Insights: Key Elements for policy center dedicated to improving the health of Successful Partnerships low-income Americans. 13 Looking Ahead Acknowledgments 13 Endnotes The authors would like to thank the organizational lead- ers who contributed their time and expertise to inform this brief: Jill Archer, Vice President of Behavioral Health at CareOregon; Stacy Brubaker, Division Manager at Jackson County Mental Health; Bess Ginty, CEO at Kids for the Future, Chair at Arkansas Healthcare Alliance, and Board Member at Empower Healthcare Solutions; Mark Heit, Senior Vice President and Regional Chief Partnerships Officer at Beacon Health Options, and Board Member at Empower Healthcare Solutions; Jennifer Lind, CEO at Jackson Care Connect; Shawn Nau, CEO at Steward Health Choice Arizona, Former President at Health Choice Integrated Care, Former COO at Northern Arizona Regional Behavioral Health Authority; John Ryan, President and CEO of Arkansas Health & Wellness, CEO of Arkansas Total Care; and Brian Turner, President and CEO at Solvista Health, Board Member at Health Colorado. About the Foundation The California Health Care Foundation is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient- centered health care system. For more information, visit www.chcf.org. California Health Care Foundation www.chcf.org 2 Background IN BRIEF Many states and regions are seeking to improve access, A growing number of states are implementing inte- quality, and costs of care for Medicaid enrollees with grated models to address problems of fragmented behavioral health needs, defined as people with men- care and poor health outcomes for individuals tal health conditions and/or substance use disorders with serious behavioral health needs. Many states (SUD). The relatively poor outcomes for these popu- have transitioned to contracting with managed lations are well documented: People with behavioral care or accountable care organizations that are health conditions have higher rates of chronic physical conditions, poor social outcomes such as homeless- responsible for managing all physical and behav- ness and unemployment, and early mortality.1 People ioral health services for Medicaid enrollees. These with behavioral health needs experience fragmented organizations commonly involve new partnerships care and receive less preventive care, while using between physical and behavioral health plans and more acute care.2 Medicaid spending for this popu- providers that can advance the goals of integrated lation is more than four times higher than for those care. This brief, produced with support from the without behavioral health conditions, largely the result California Health Care Foundation, identifies key of increased physical health care spending.3 Informed elements that contribute to successful partner- by the growing evidence that clinical integration of ships. It synthesizes insights from organizational physical and behavioral health can improve health leaders representing Medicaid-based partnerships outcomes and quality of life as well as reduce health in Arizona, Arkansas, Colorado, and Oregon. Key care costs, many states have sought to advance inte- elements include (1) employing joint-ownership grated care for Medicaid beneficiaries with behavioral models representing both physical and behavioral health needs.4 health, (2) ensuring stable system transitions for Separate financing and administrative structures for consumers and providers, (3) marrying the expertise physical and behavioral health care in Medicaid can of physical and behavioral health partners to create contribute to fragmented care. While the majority of new and enhanced capacities, and (4) allowing states organize and finance physical health benefits adequate time for planning and implementation. through managed care organizations (MCOs), histori- These lessons are broadly applicable for health care cally many states “carved out” the administration of organizations and policymakers considering how to specialty mental health and SUD services to separate support successful partnerships to advance physical managed behavioral health organizations (often pub- and behavioral health integration. lic entities) or on a fee-for-service basis. Under such systems, with different care components managed by disparate entities, consumer access to care and care coordination can be diminished, often resulting in worse health outcomes.5 States seeking more integrated physical and behavioral health care in their Medicaid programs are pursuing a variety of approaches including integrated managed care, health homes, and accountable care organiza- tions (ACOs).6 A growing number of states have newly contracted with either integrated managed care plans or ACOs to manage all physical and behavioral health services for Medicaid enrollees. The structure of these Making Integration Work: Key Elements for Effective Partnerships Between Physical and Behavioral Health Organizations in Medicaid 3 models — including the populations covered, phasing behavioral health organizations. However, regardless of implementation, and structure and responsibility of of which option is selected, partnerships between contracted entities — varies widely, as states often physical and behavioral health stakeholders — includ- tailor policy approaches to address unique state and ing both administrators and providers — often emerge. regional environments as well as existing managed These partnerships can take many forms, ranging from care and provider capacity. As of 2019, only nine formal to more informal relationships, and may have states carve out behavioral health benefits — a signifi- responsibility for an entire state or a specific region. cant decrease over the last decade.7 While there are How well such partnerships function can have a sig- limited data on the impact of these state integrated nificant impact on efforts to advance integrated care.10 managed care initiatives, evaluations from Arizona and Washington have shown promising results.8 To examine how partnerships have advanced physical and behavioral health integration — and to identify In this evolving landscape, there is much to learn from lessons for states and other stakeholders — the Center states, plans, and providers that have advanced inte- for Health Care Strategies (CHCS), with support from gration efforts, both in terms of strategies to support the California Health Care Foundation, conducted effective implementation and impacts on care delivery interviews with leaders of organizations that are and outcomes. Their experiences thus far have shown partnering to integrate care for Medicaid enrollees. that financial integration alone is not sufficient for clini- Interviewees represented both physical and behav- cal integration — data-sharing and payment policies ioral health care in four states: Colorado and Oregon, are critical.9 But to understand the key elements for which have regional Medicaid ACOs, and Arizona successful integration, it is also necessary to exam- and Arkansas, which have integrated specialty health ine the partnerships between physical and behavioral plans for those with serious behavioral health needs. health entities that undergird integration. Through their integration efforts, the profiled states When states consider changing how behavioral health and regions experienced significant transformation in benefits are managed, often the debate centers how behavioral and physical health services were man- around which entities are best positioned to man- aged. Details on the interviewees and their integration age an integrated benefit, with options commonly models are summarized in Table 1 and described in including physical health MCOs and public or private the next section. Table 1. Overview of Profiled Partnerships and Characteristics, by State INTEGRATION MODEL PARTNERSHIP SCOPE ENTITY INTERVIEWED PARTNER(S) Arizona Integrated Regional Behavioral Health Joint ownership Health Choice Steward Health Choice Authorities (RBHAs). Specialty managed between 2015 and Integrated Care Arizona* care plans for adults with serious mental 2018 (duration limited (now Health Choice Arizona) health needs by design) Arkansas Provider-Led Arkansas Shared Savings Joint ownership $ Empower $ Beacon Health Options, Entities (PASSEs). Specialty managed care since 2018 Healthcare Arkansas Healthcare plans for adults and children with serious Solutions Alliance behavioral health needs or intellectual or $ Arkansas $ Arkansas Health & developmental disabilities Total Care Wellness (a Centene subsidiary) Colorado Regional Accountable Entities (RAEs). Joint ownership Health Colorado Beacon Health Options, Medicaid ACOs cover all adults and children since 2019 Solvista Health Oregon Coordinated Care Organizations (CCOs). Informal Jackson Care Jackson Care Connect, Medicaid ACOs cover all adults and children partnership Connect CareOregon, Jackson County Mental Health *After the interview was conducted, Blue Cross Blue Shield of Arizona acquired Steward Health Choice Arizona, and “Steward” was dropped from the name. California Health Care Foundation www.chcf.org 4 hybrid approach that merged provider leadership with Profiled Partnerships the expertise of managed care organizations.12 Arizona These new entities, known as Provider-Led Arkansas Arizona’s Medicaid agency began integrating the Shared Savings Entities (PASSEs), cover approximately financing of physical and behavioral health in 2013, 44,000 adults and children enrolled in Medicaid after having carved out specialty behavioral health with high levels of behavioral health or IDD service benefits to Regional Behavioral Health Authorities needs, and are now fully at risk for all enrollees after (RBHAs) for many years. To promote integration, a multiphase launch.13 PASSEs manage all physical beginning in 2014 the state carved physical health and behavioral health services as well as home- and benefits into RBHA contracts for adults with seri- community-based long-term services and supports. ous mental illness (SMI) and required that integrated Each PASSE must organize and coordinate across RBHAs include a physical health plan. A single inte- the full continuum of care, including development of grated RBHA in each of three regions managed care a statewide provider network and provision of care for this population. coordination services. The program has been quickly implemented — after passage of enabling legislation The integrated RBHA profiled in this brief, Health in 2017, PASSEs began providing care coordination Choice Integrated Care (Health Choice), was a joint ven- services to attributed beneficiaries in February 2018, ture between Steward Health Choice Arizona (Steward) and in March 2019 became fully at risk for all services and the Northern Arizona Regional Behavioral Health and began receiving a global capitated payment. The Authority (NARBHA). While NARBHA was a behavioral state structured this phased launch to enable PASSEs health plan, it was owned by behavioral health pro- to test their approaches and to use full claims data for viders in the region and thus was closely connected approximately one year before becoming fully at risk. to providers. Health Choice covered six counties in northern Arizona, including the cities of Flagstaff and In the PASSE model, the state requires that different Prescott. In 2018, as the state expanded its integration providers — including a behavioral health services strategy to include most Medicaid enrollees, Steward provider, developmental disability service provider, assumed further responsibility as an integrated plan physician, hospital, and pharmacist — enter into a for the general population. At this time, it bought out partnership with an organization that manages admin- NARBHA’s portion of the integrated RBHA contract for istrative functions, with the providers retaining majority the SMI population and developed a new contractual ownership. Of three statewide PASSEs, two are pro- relationship allowing NARBHA to have an ongoing filed in this brief: Arkansas Total Care, owned by two role advising on services for members with SMI. provider groups and by Arkansas Health & Wellness (a subsidiary of Centene, a national managed care plan), and Empower Healthcare Solutions (Empower), Arkansas owned by five provider groups as well as by Beacon Arkansas developed a unique partnership model of Health Options, a national behavioral health managed risk-based provider organizations that integrate spe- care plan. cialized services for adults and children with either severe or persistent behavioral health needs, or intel- lectual and developmental disabilities (IDD). The state Colorado chose to focus on these high-need populations due Colorado sought to promote integration of physical to their rising costs of care, limited access to care, and health, mental health, and SUD services while main- fragmented delivery of service in the state’s fee-for- taining separate financing streams for physical and service system, with the goal of developing a model to behavioral health. In 2011, under the first phase of achieve savings within five years.11 Arkansas pursued a Colorado’s delivery system transformation, the state Making Integration Work: Key Elements for Effective Partnerships Between Physical and Behavioral Health Organizations in Medicaid 5 focused on strengthening primary care, creating CCOs initiated this move earlier, and the experience Regional Care Collaborative Organizations (RCCOs) to of the Jackson Care Connect CCO, outlined in this coordinate care across primary and specialty care on brief, illustrates how organizations can evolve their a fee-for-service basis. Meanwhile, Behavioral Health partnerships to navigate significant transitions in orga- Organizations (BHOs) continued to manage a carved- nizational responsibilities. Oregon first introduced out benefit as they had done previously. CCOs in 2012, as locally governed regional collab- oratives that included health plans, providers, county In 2018, the second phase of transformation began, public health, and community-based organizations that with a focus on advancing integration of physical and administer a single global budget to serve Medicaid behavioral health services and making one entity enrollees regionally.17 While CCOs are a type of ACO accountable at the administrative level for these — referred to by some as “ACOs on steroids” — their services to increase providers’ ability to deliver whole- financing structure more closely resembles Medicaid person care.14 Regional Accountable Entities (RAEs) managed care organizations.18 Initially, most CCOs replaced both the RCCOs and BHOs, and became carved out the behavioral health benefit by passing responsible for administering the capitated behavioral through a portion of the global budget to local men- health benefit as well as overseeing an expanded scope tal health agencies, with reported negative outcomes of care coordination activities and increased account- including limited access to care, delayed authoriza- ability among primary care providers still operating tions, and barriers to advancing clinical integration.19 under a fee-for-service reimbursement model. The RAEs were responsible for contracting with primary Jackson Care Connect CCO had originally partnered care providers to serve as medical homes, building with Jackson County Mental Health (Jackson County), a statewide network of behavioral health providers, the local mental health agency, which served as both coordinating care across all providers, and monitor- the subdelegated behavioral health managed care ing data and improving population health across the entity for all members and as the primary provider of region. Since this phase began, RAEs are increasingly services for a high-need subpopulation. Both entities incentivized to achieve improved member outcomes are located in Jackson County in southern Oregon, across physical and behavioral health indicators, and one of the more populous counties in the state and may use value-based payments in their contracts with home to the cities of Medford and Ashland. In 2016, behavioral health and primary care providers.15 Health Jackson Care Connect opted to carve in the behavioral Colorado, profiled in this brief, covers over 130,000 health benefit to address the fragmented care experi- members across 19 counties in primarily rural and enced by members with behavioral health needs, and frontier south-central and southeastern regions of the to pare back on the services for which it contracted state, and is jointly owned by four community mental with the county to deliver. This partnership underwent health centers (CMHCs), a Federally Qualified Health a significant transition, with Jackson County limiting its Center (FQHC), and Beacon Health Options. One scope to a more targeted set of services, primarily for other RAE is partially owned by CMHCs and FQHCs, high-need adult and youth members, including crisis and the remaining RAEs have varied ownership struc- and safety-net services, outpatient treatment, assertive tures, including plans as sole operators.16 community treatment, wraparound services, special- ized services for forensics populations, and mental health court. While the scope of services that Jackson Oregon County provides is significantly narrower, the county In January 2020, Oregon implemented a significant continues to participate in the board of directors and initiative to address the fragmentation of physical clinical advisory panel for Jackson Care Connect, and and behavioral health services, with all of the state’s both organizations collaborate in the development Coordinated Care Organizations (CCOs) becoming and management of a county-level behavioral health fully accountable for behavioral health services. Some strategic plan. California Health Care Foundation www.chcf.org 6 Insights: Key Elements ownership between physical health plans and behav- ioral health plans or providers, and in states that did for Successful not. For example, all Arkansas PASSEs are statutorily required to be majority-owned by providers repre- Partnerships senting a range of practice types, while Colorado has Through interviews with leaders of physical and no such requirement, and only some of the Colorado behavioral health organizations, CHCS identified a set RAEs, including Health Colorado, are jointly owned by of elements underpinning successful partnerships: plans and providers focused on physical and behav- ioral health. Interviewees underscored the importance 1.Employ joint-ownership models that include of joint ownership in transforming their operations and both physical and behavioral health entities. in navigating challenges that can arise when bringing 2.Ensure stable system transitions for consum- together leaders with different perspectives and busi- ers and providers. ness interests. 3.Marry the expertise of physical and behav- These joint-ownership models bring together plans ioral health partners to create new and and providers to collaborate in the design of man- enhanced capacities. aged care functions and require accountability for 4.Allow adequate time for planning and integrated care outcomes that extend beyond the implementation. measures that physical or behavioral health entities may be accustomed to assessing. While organizations These key ingredients may be broadly applicable for may come into the partnership with divergent inter- health care organizations and policymakers consider- ests, joint ownership creates new financial stakes, and ing how to support successful partnerships as part of shared governance creates new pathways for mak- broader strategy to advance physical and behavioral ing key decisions. Owners in the Empower PASSE in health integration. Following is a discussion of each Arkansas shared how they codesigned strategies for of these elements based on insights gleaned from medical necessity criteria, care management, and pro- the four featured states and their efforts to collec- vider reimbursements with the goal of creating shared tively advance integrated care across changing policy benefits among behavioral health providers, hospitals, environments. primary care providers, IDD providers, and the health plan, even when some of the proposed changes would potentially hurt one partner. Various Empower part- Employ joint-ownership ELEMENT 1 ners characterized this process as transformative — a models that include both physical health plan leader called it “a natural and healthy ten- and behavioral health entities. sion in how managed care is brought to bear,” while a Joint ownership of integrated entities, as exists with provider leader said, “It’s eye-opening to wear a pro- the Arkansas PASSEs, some Colorado RAEs, and inte- vider hat and an insurer hat, because sometimes these grated RBHAs in Arizona before 2018, can create things do not agree.” The provider leader shared that new incentives and help align different organizations the experience of governing Empower fundamentally around shared goals. Many of these joint-ownership changed the perspective of all governing partners models knit together different systems — such as to be mindful of how reshaping the delivery of care behavioral health, physical health, and in the case may improve member outcomes, and to simultane- of Arkansas PASSEs, home- and community-based ously prepare themselves to be nimble in response services — through shared governance and shared to potential changes in revenue. While profiled enti- ownership of the partnership entity. Notably, these ties within and across states had different governance arrangements arose both in states that required joint structures, a health plan leader said that for Empower Making Integration Work: Key Elements for Effective Partnerships Between Physical and Behavioral Health Organizations in Medicaid 7 PASSE, equity in governance participation is “the most design that is financially sustainable for providers meaningful requirement to bring the cross-functional delivering behavioral health services to high-need parts of the health care system together to manage members. For providers facing dramatic changes the membership on a holistic basis.” related to physical-behavioral health integration, par- ticipating in a joint-ownership partnership can support For the owners of Health Colorado RAE, which include providers to, as a plan leader said, “define their own community-based physical and behavioral health pro- destiny rather than have someone else define it for viders as well as Beacon Health Options, the diversity of you.” Many behavioral health providers lack the finan- perspectives among partners is both the biggest chal- cial capital to manage financial risk across physical lenge and the greatest catalyst for change. Partners are and behavioral health care, and are reliant on volume- forced to think beyond their individual organizational based services based on specific behavioral health interests, sharing the responsibility and risk of man- funding streams. Joint-ownership models may enable aging care for Medicaid enrollees across the region. providers to move toward value-based, coordinated “The entire design of this new system is based on care that advances integration. As a health plan leader improving coordination around the health care supply in the Arkansas Total Care PASSE said, “Providers want chain,” a behavioral health provider leader in Health and deserve to play a more active role in population Colorado said. “Partnering without being contentious health management and value-based purchasing.” takes communication, patience, compromise, and cul- Being a part of an organization like this PASSE gives ture change, which is a big shift in health care.” This providers, from the perspective of this plan leader, leader described how the partnership creates a reason “more stake in the game and more control in the for physical and behavioral health providers to work delivery system and model of care.” A provider leader together even when their financial interests may seem in a PASSE observed that participating in a joint-own- to differ. For example, to promote greater clinical inte- ership model allows behavioral health providers to gration, Colorado recently added a Medicaid benefit shape system changes to strengthen their work and for a limited number of behavioral health visits within potentially avoid provider closures that could reduce primary care settings to be billed under the physical access to care. health fee-for-service system. In regions of the state served by other RAEs, this new benefit may have had Ultimately, as a Beacon Health Options interviewee the unintended consequence of incentivizing physi- working with both the Arkansas PASSE and Colorado cal health providers to limit their collaborations with RAE models said, integrating care for those with the external behavioral health providers, instead limiting most severe needs remains a persistent challenge integration efforts to those services that they can pro- across the country, with no easy solutions. However, vide and bill for in-house. By contrast, Health Colorado this plan interviewee suggested that “there is no focused on leveraging this new benefit to create a way to advance the ball without engaging providers more integrated model between physical and behav- directly to realign the organizational and financing ioral health services, through better referral pathways structures to the clinical redesign needed to drive and opportunities for co-location and integration. The improved outcomes at the local, community level.” As structure of the Health Colorado RAE, with shared a plan interviewee in Arkansas Total Care explained, ownership between physical and behavioral health the shared ownership model of the PASSE will help providers, creates a clear business rationale for these “force innovation and bring creativity to the front” to providers to work together and avoid turf battles for structure provider reimbursements based on agreed- resources. upon quality measures and incentives that foster the most desirable outcomes. With the evolution of PASSE When behavioral health entities have a seat at the and other joint-ownership models, their experiences table to shape how integrated services are managed in designing new value-based payment approaches and delivered, they can also help prioritize a system are likely to provide additional valuable insights. California Health Care Foundation www.chcf.org 8 turn it on” — with sustained stakeholder engagement ELEMENT 2 Ensure stable system essential to achieving that understanding. transitions for consumers and providers. Successful partnerships can support behavioral health Transitioning to new models for financing, deliver- providers navigating potentially disruptive transitions ing, and reimbursing behavioral health services can and collaboratively solve problems. For behavioral be disruptive for consumers as well as providers. health providers transitioning from billing the state Successful partnerships, however, can optimize the fee-for-service or on a contract basis to billing multiple unique strengths of individual organizations to focus managed care entities, as in Arkansas’s PASSE transi- on consumer and community needs and to mitigate tion, submitting claims and receiving payment could transition challenges. Partnerships are well positioned create major problems for providers operating with to lead robust stakeholder engagement inclusive of narrow margins. Partnerships that actively engage providers, advocates, and consumers. A partnership providers may be better positioned to identify these structure can also create new models for sustainabil- problems early and develop solutions quickly, espe- ity for behavioral health organizations transitioning to cially during a transition to new billing systems. A plan redefined responsibilities. interviewee of the Arkansas Total Care PASSE said that “being provider-sponsored caused us to have a higher Partnerships that use consumer and provider input sensitivity to provider challenges,” especially during to tailor the transition approach to integrated care the transition to becoming fully at risk for all services. can engender greater buy-in among stakeholders. In the experience of this plan partner, the dynamic of Community-based behavioral health organizations this partnership model changes how both the plan are particularly well positioned to engage consum- and providers (including equity partners and other ers and providers to facilitate smoother transitions to providers) participate. Providers in the Arkansas Total integrated care. A behavioral health provider partner Care PASSE model have been much more engaged in in the Health Colorado RAE noted that local behav- policies and procedures, addressing questions such as ioral health providers represent the needs of and are how to best ensure that claims are filed and paid. Often accountable to their communities, which fundamen- these conversations were driven by an immediate oper- tally strengthens their ability to design systems that ational issue but evolved into a broader conversation improve community outcomes. Through its commu- about the best strategy to improve providers’ ability nity-based focus, Health Colorado could also more to deliver care that can improve consumer outcomes. successfully engage cross-sector entities, including schools and criminal justice agencies, to partner with Additionally, behavioral health provider partners are RAE and collaborate on community-wide approaches. well positioned to identify and share transition-related While Arkansas Total Care does not include a locally problems that consumers experience, which can help based behavioral health provider among its joint own- partnerships mitigate these issues. When Arkansas ers, the PASSE did engage advocacy groups, provider providers reported to the Empower PASSE that some associations, and consumers early in its development. members were being placed in the wrong level of ser- A plan partner in the Arkansas Total Care PASSE vices due to statewide challenges in completion of an described the importance of early and frequent con- independent assessment, Empower sought to iden- versations with stakeholders to understand their tify members at risk of incomplete assessments and experiences and challenges under the previous sys- develop a strategy to complete them. An interviewee tem. When the PASSEs transitioned to a full-risk model at one of Empower’s provider partners said that hav- in 2018 and became responsible for many new ser- ing providers in this leadership role enabled Empower vices, from this interviewee’s perspective “you don’t to quickly pivot to develop solutions that better serve just turn that on, you have to understand the way to consumers and providers. In Oregon, when Jackson Making Integration Work: Key Elements for Effective Partnerships Between Physical and Behavioral Health Organizations in Medicaid 9 Care Connect CCO shifted the management of the ELEMENT 3 Marry the expertise of behavioral health benefit and the provision of many physical and behavioral health specialty mental health services away from Jackson County in 2016, the two organizations collaborated partners to create new and to transition consumers with behavioral health needs enhanced capacities. to new providers. Jackson County said that partnering Physical and behavioral health organizations — includ- with Jackson Care Connect led to a well-designed pro- ing both plans and providers — have distinct areas of cess that put the needs of vulnerable consumers first, expertise shaped by the history, culture, and practice which “helped to minimize the impact” with the goal of their traditionally independent systems. Successful of “making it as seamless as possible for clientele.” partnerships to advance integrated care create shared new capacities, expertise, and culture forged by col- Finally, as systems continue to evolve, partnerships laboration between partners, providing value greater may create new pathways for sustainability for indi- than the sum of their parts. As a result, these partner- vidual organizations. After transitioning the behavioral ships can leverage their combined expertise to design health benefit and many services away from Jackson and implement administrative and clinical processes, County, Jackson Care Connect CCO in Oregon and innovations in service delivery, to effectively meet focused on working with the county to stabilize and community needs and to improve member health out- explore different ways of maintaining the county’s role comes. In particular, where physical health plans have as a service provider. Jackson Care Connect began a leadership role in managing integrated care, such contracting with Jackson County to provide addi- as in Arizona and in Oregon’s Jackson Care Connect tional services for specific populations, finding that CCO, partnerships with behavioral health stakehold- the county brought unique strengths in working with ers can help the plans to change the culture and high-need groups, such as young people experienc- underlying capacities of their plans. ing early symptoms of psychosis and justice-involved populations. In interviews, both partners described Interviewed health plan leaders in both Arizona and now having shared ownership of the behavioral Oregon agreed that culture shifts were among the health system in the county, with greater transpar- biggest challenges for their organizations in imple- ency about their responsibilities and roles. Notably, menting financial integration. In the words of a Jackson County wrote a letter of support for Jackson Jackson Care Connect interviewee from Oregon, it Care Connect’s 2019 CCO application, which noted is important “not to underestimate what it takes to “since [Jackson Care Connect] began managing the change a physical health plan to a global health plan.” behavioral health system directly, [their] partnership Partnerships with behavioral health entities enabled has grown to even deeper levels.”20 This testimo- these plans to develop new capacities to manage inte- nial to the strength of their partnership is especially grated care, with improved member outcomes. Plan noteworthy given these organizations’ history, with interviewees said that prior to 2016, when Jackson Jackson County experiencing significant organiza- Care Connect delegated the behavioral health ben- tional disruption and layoffs three years earlier. As efit to Jackson County, its staff held the entrenched another example of new partnership opportunities, belief that behavioral health would be too different when the shared contract to manage the integrated and complex to manage within a traditional physical plan for SMI ended in Arizona in 2018, Steward (the health plan. When the benefit was carved in, Jackson health plan that began managing an integrated ben- Care Connect turned to Jackson County for its exper- efit) developed a new contractual arrangement with tise and adopted county processes to inform Jackson NARBHA, the prior regional behavioral health plan, to Care Connect’s approach to managing an integrated continue their partnership toward improving care for benefit. Jackson Care Connect’s efforts included (1) this population. conducting comprehensive staff education, (2) incor- porating behavioral health processes and providers California Health Care Foundation www.chcf.org 10 into the existing system, and (3) pursuing internal services, Empower is working to develop solutions to integration of staff and programmatic approaches, complex issues such as addressing ambulance funding including hiring many more social workers to lead for transportation to non-emergency room settings. teams and drive care coordination, a substantially dif- Empower is also looking to expand telehealth utili- ferent model than it previously employed. As a result, zation and to implement other innovations to better Jackson Care Connect reported improved access to coordinate care for those with serious physical and/or mental health services and reduced costs among its behavioral health needs. members, with the penetration rate for mental health services increasing from approximately 12% to 19%, Similarly, Jackson Care Connect and Jackson County and an over 9% reduction in the cost per member in Oregon are continuously codeveloping new initia- served.21 tives to serve members with complex health and social needs. For example, the two organizations have col- In Arizona, Steward and NARBHA partnered to code- laborated to increase access to medication-assisted velop a new integrated care management strategy treatment, link individuals with co-occurring SUD and while preparing their bid for the integrated contract. physical or mental health needs with other providers, Based on a member survey that identified flaws in the and expand mobile crisis response. Additionally, the existing care management strategy for adults with partners have collaborated on jail-diversion activities SMI, the partners decided to pursue an integrated and on developing an outpatient behavioral health approach, leveraging health homes based in commu- forensics team. Jackson Care Connect and Jackson nity mental health settings. To implement this model County have worked with other agencies, including the and to support physical and behavioral health provid- Jackson County Sheriff’s Office, to open a Community ers in working together, Health Choice hired new care Justice Resource Center to help members leaving jail management staff to be the “glue” between these or prison to access needed resources. These initiatives different provider systems, as many providers did not demonstrate how a partnership approach may, in the have staff trained to coordinate across these different words of a Jackson Care Connect interviewee, “allow services. Among the highest-need tier of members for optimizing the strengths of each organization,” with SMI served in this program, Steward reported and lead to new opportunities for public behavioral overall cost savings of 7% to 8% as a result of major health plans to take on a new role, such as focusing on decreases in inpatient spending along with moderate cross-sector collaboration to address key unmet com- increases in physical and behavioral health outpatient munity and member needs. spending.22 Interviewed plans also reported steady or slightly improved outcomes related to member and provider satisfaction and quality of care. ELEMENT 4Allow adequate time for planning and implementation. Partner collaboration may also lead to the design of Partnerships benefit from strong alignment between improved clinical services, such as better referral and partners related to long-term goals and strategy, coordination pathways between primary care and but rapidly paced timelines for standing up new behavioral health providers. In Arkansas, Empower integrated care models, as well as unexpected pol- partners (who manage physical and behavioral health icy shifts, can be particularly destabilizing for these as well as home- and community-based services) are arrangements. Many states have implemented finan- working together to develop a mobile crisis system cial integration as part of a multiphase process, but for individuals with developmental disabilities and with considerable variation in both in implementa- behavioral health needs to ensure access to highly tion timelines and in transparency about the overall responsive services in times of greatest need.23 By direction of policy change. While interviewed partners leveraging partners with expertise in acute care as described their efforts to adapt to these issues, includ- well as community-based behavioral health and IDD ing through leveraging preexisting relationships, they Making Integration Work: Key Elements for Effective Partnerships Between Physical and Behavioral Health Organizations in Medicaid 11 also identified adequate time and planning as critically Arizona emphasized a transparent integration-rollout important for stakeholders and policymakers inter- process with a multiyear plan for how populations ested in setting up partnerships to succeed. would be phased into an integrated benefit, which may have better positioned partners to navigate chal- When a physical and behavioral health partnership lenges. Arizona’s purpose in designing the integrated model must be achieved on a short timeline, organi- specialty plan model for physical and behavioral zations struggle to develop new processes. Partners health plans as it did was to begin learning how to from different worlds have a lot to learn, and rushed manage integrated benefits, with the understanding decisions can lead to long-term tensions that ham- that the initial plans were a transitional product that per collaboration. As a plan interviewee observed, would be incorporated for the general population at in these models it can be “difficult to reconcile the a later date. As an interviewee at Steward described, pace with which government wants to move with the this approach helped to “ease organizations into the reality of how long it takes to operationalize those transition toward integration” by phasing in different challenges.... We need to both have aspirational populations. While the model created some chal- state regulations and the necessary time to imple- lenges, including for providers navigating new claims ment them on the ground.” A plan interviewee at one and payment policies as well as for partners who PASSE, Arkansas Total Care, identified one of the most had to negotiate new contracts twice in a three-year important considerations for state policymakers inter- period, from the perspective of the plan the partner- ested in ensuring access to integrated care as taking ship succeeded in its goal to be “a vehicle to help the necessary time to “let the model work” and being guide the transition to integration.” mindful that “transformational work takes time.” In another Arkansas PASSE, Empower, plan and provider Across different state processes — and especially in partners both identified the difficulties of adapting those with fast timelines to implement new models — to ongoing regulatory changes and described how organizations benefit from partnering with established frequent changes can leave partners as well as the organizational relationships. Multiple interviewees broader provider community struggling to remain characterized their relationships with partners as focused on big-picture goals. going back decades, and said that these preexist- ing relationships facilitated the development of a These challenges can be particularly pronounced for new organization. Because partners need to quickly local behavioral health plans and providers that are develop bids, governing agreements, and plans, often smaller than larger physical health partners. these preexisting relationships can help to accelerate Behavioral health providers said that it is hard to com- their work. A plan interviewee shared that working with mit limited resources to developing new models when longstanding partners “fundamentally changes the policy, regulatory, and contractual requirements can learning curve and relative capabilities of the [partici- quickly change. As a Health Colorado provider inter- pating] organizations.” Whether or not partners have viewee said, provider partners of the RAE must “shift longstanding relationships, strong working relation- how they allocate resources to ensure that they are on ships are essential. In the words of a behavioral health top of not only what is currently required, but in antici- provider partner, integrated care in Medicaid requires pation of what the state may want them to do in the “finding a group of people that can collaborate to future.” The uncertainty can lead to inefficiencies and create a better system.” As states prepare for major ineffectiveness. This interviewee offered that partners system transitions, they should consider opportuni- can better work together in models that are “iterative ties to seed or otherwise support the development of without being unpredictable.” Thus, models should partnerships that can provide important foundations enable innovation while also supporting longer-term for long-range strategic goals. investments in system transformation. California Health Care Foundation www.chcf.org 12 Looking Ahead Successful physical-behavioral integration approaches Endnotes often bring together physical and behavioral health 1. Behavioral Health in the Medicaid Program — People, Use, and Expenditures, Medicaid and CHIP Payment and Access organizations as partners in designing and imple- Commission (MACPAC), June 2015, www.macpac.gov (PDF); menting new models of care. States interested in Martha R. Burt et al., Homelessness: Programs and the advancing physical-behavioral health integration in People They Serve | Findings of the National Survey of Medicaid, including through developing or refining Homeless Assistance Providers and Clients, Urban Institute, December 7, 1999, www.urban.org; Alison Luciano and Ellen integrated managed care or ACO models, may ben- Meara, “Employment Status of People with Mental Illness: efit from applying the lessons of partnerships that National Survey Data from 2009 and 2010,” Psychiatric have emerged and matured in other states. Leaders Services 65, no. 10 (October 2014): 1201–9, doi:10.1176/ in partnering organizations interviewed for this brief appi.ps.201300335; and Joe Parks et al., Morbidity and Mortality in People with Serious Mental Illness, National Assn. identified key ingredients that can best position these of State Mental Health Program Directors, October 2006, partnerships to succeed in designing, implementing, www.northernlakescmh.org (PDF). and improving system changes to meet the compre- 2. David Lawrence and Stephen Kisely, “Inequalities in hensive health needs of members and communities. Healthcare Provision for People with Severe Mental Illness,” These lessons reflect the importance of designing an Journal of Psychopharmacology 24, Suppl. 4 (2010): 61–68, doi:10.1177/1359786810382058; and Karen Abernathy et overall policy approach, timeline, and requirements al., “Acute Care Utilization in Patients with Concurrent Mental that best position key stakeholders to innovate and Health and Complex Chronic Medical Conditions,” Journal achieve more integrated care. of Primary Care and Community Health 7, no. 4 (Oct. 2016): 226–33, doi:10.1177/2150131916656155. 3. Behavioral Health in the Medicaid Program — People, Use, and Expenditures, MACPAC, June 2015, www.macpac.gov. 4. Emily Woltmann et al., “Comparative Effectiveness of Collaborative Chronic Care Models for Mental Health Conditions Across Primary, Specialty, and Behavioral Health Care Settings: Systematic Review and Meta-Analysis,” American Journal of Psychiatry 169, no. 8 (Aug. 2012): 790–804, doi:10.1176/appi.ajp.2012.11111616; and Brenda Reiss-Brennan et al., “Association of Integrated Team-Based Care with Health Care Quality, Utilization, and Cost,” JAMA 316, no. 8 (2016): 826–34, doi:10.1001/jama.2016.11232. 5. Integrating Clinical and Mental Health: Challenges and Opportunities, Bipartisan Policy Center, January 2019, bipartisanpolicy.org (PDF). 6. Integration of Physical and Behavioral Health Services in Medicaid, MACPAC, March 2016, macpac.org (PDF). 7. Some states have different arrangements for different populations. For more information, see Kim Tuck and Erin Smith, Behavioral Health Coverage in Medicaid Managed Care, Institute for Medicaid Innovation, April 2019, www.medicaidinnovation.org (PDF) and Athena Mandros, “Do States Still Have Medicaid Behavioral Health Carve- Outs?,” Open Minds, February 21, 2019, openminds.com. Making Integration Work: Key Elements for Effective Partnerships Between Physical and Behavioral Health Organizations in Medicaid 13 8.Independent Evaluation of Arizona’s Medicaid Integration 16.Jeff Bontrager et al., The Ways of the RAEs: Regional Efforts: Programs for Children’s Rehabilitative Services Accountable Entities and Their Role in Colorado Medicaid’s and Persons Determined to Have a Serious Mental Newest Chapter, Colorado Health Institute, October 2018, Illness, Arizona Health Care Cost Containment System, www.coloradohealthinstitute.org (PDF). November 27, 2018, www.azahcccs.gov; David Mancuso, 17.Lauren Broffman et al., “Funding Accountable Care in Evaluation of Fully Integrated Managed Care in Southwest Oregon: Financial Models in Two Coordinated Care Washington: Preliminary First-Year Findings, Washington Organizations,” Journal of Healthcare Management 61, no. 4 State Dept. of Social and Health Services, August 31, 2017, (July/Aug. 2016): 291–302, www.ncbi.nlm.nih.gov. www.hca.wa.gov (PDF). 18.Teresa A. Coughlin and Sabrina Corlette, ACA 9.Logan Kelly, Michelle Conway, and Michelle Soper, Exploring Implementation — Monitoring and Tracking: Oregon Site the Impact of Integrated Medicaid Managed Care on Visit Report, Urban Institute, March 2012, www.urban.org Practice-Level Integration of Physical and Behavioral Health, (PDF); and K. John McConnell et al., “Oregon’s Medicaid Center for Health Care Strategies, July 2019, www.chcs.org; Reform and Transition to Global Budgets Were Associated Ashley Palmer and Anne Rossier Markus, “Supporting with Reductions in Expenditures,” Health Affairs 36, no. 3 Physical-Behavioral Health Integration Using Medicaid (March 2017): 451–59, doi:10.1377/hlthaff.2016.1298. Managed Care Organizations,” Administration and Policy in Mental Health and Mental Health Services Research (Oct. 29, 19.CCO 2.0 Recommendations of the Oregon Health 2019, published ahead of print): 1–9, doi:10.1007/s10488- Policy Board, Oregon Health Authority, October 2018, 019-00986-3; and Maureen T. Stewart et al., “The Role of www.oregon.gov (PDF); and Jason Kroening-Roché et al., Health Plans in Supporting Behavioral Health Integration,” “Integrating Behavioral Health Under an ACO Global Budget: Administration and Policy in Mental Health and Mental Health Barriers and Progress in Oregon,” American Journal of Services Research 44, no. 6 (Nov. 2017): 967–77, doi:10.1007/ Managed Care 23, no. 9 (Sept. 2017): e303–e309. s10488-017-0812-3. 20.Mark Orndoff, letter of recommendation for Jackson Care 10.Palmer and Markus, “Supporting Integration.” Connect, April 2019. 11.Provider-Led Arkansas Shared Savings Entity (PASSE): 21.Jill Archer, personal communication, November 15, 2019. Journey to the PASSE, Arkansas Foundation for Medical 22.Shawn Nau, personal communication, September 30, 2019. Care, 2018, www.afmc.org (PDF); and Provider-Led Arkansas Shared Savings Entity (PASSE): Risk-Based Provider 23.Including Individuals with Intellectual/Developmental Organizations Under Title XIX Section 1915(b) Authority, Disabilities and Co-Occurring Mental Illness: Challenges That Arkansas Dept. of Human Services, June 27, 2017, Must Be Addressed in Health Care Reform, National Assn. for humanservices.arkansas.gov (PDF). the Dually Diagnosed, n.d., www.aaidd.org (PDF). 12.Organizations Under Title XIX, Arkansas Dept. of Human Services. 13.Arkansas Department of Human Services and PASSEs Respond to Feedback, Adjust Open Enrollment and Transition Period, Arkansas Dept. of Human Services, April 30, 2019. 14.“Ways of the RAEs: Colorado’s Medicaid Director Discusses the Accountable Care Collaborative,” n.d., in The Checkup: The Colorado Health Institute Podcast, podcast, 21:12, soundcloud.com. 15.Performance Measurement: Accountable Care Collaborative Phase II June 2018, Colorado Dept. of Health Care Policy & Financing, June 2018, www.colorado.gov (PDF); and Regional Accountable Entity: The Accountable Care Collaborative (ACC) Key Performance Indicators (KPI) Methodology, SFY 2018–2019, Colorado Dept. of Health Care Policy & Financing, May 2019, www.colorado.gov (PDF). California Health Care Foundation www.chcf.org 14