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Health Care Integration


 

What model will best reduce this disparity the quickest?

Of course, I am a member of MPS and have a bias in my view of this situation (reader beware). But the entire behavioral health advocacy community is coming together to recommend what it thinks is the best financial and administrative framework within which to provide the greatest good. We need to decide, by the end of September, which infrastructure model to use in order to provide more “integrated” health care.

Will it apply equally, regardless of illness severity?

Will it incorporate both somatic health and behavioral health, connecting the brain and the body again? Or will it keep them separate but equal?

Keep track at http://bit.ly/Ouptue.

The data provided by the Maryland’s Integration Data Work Group [The chart is based on this data] clearly and profoundly demonstrate this disparity in chronic medical problems among the 200,000 or so HealthChoice enrollees. People identified as having a mental health illness are medically admitted 2 to 4 times more often for diabetes, heart failure, infections, epilepsy, and pulmonary disease than are people without any behavioral health condition. People identified as having a substance use disorder are medically admitted 4 to 7 times more often than people without any behavioral health condition. And, for people who have both mental health and substance use illness, these people are admitted 8- to 15-times more often than those without.

We estimated the cost for hospitalization for these six medical categories alone, and only for the 19-64 year old age group that we analyzed, to be about $86 million in excess costs over and above what would be expected for people without a behavioral health illness. A full analysis of this data would likely demonstrate more than $150 million in excess costs, much of which is avoidable with improved outpatient care.

The MPS believes that a model that is most likely to adopt a culture of integration is also the one that will most likely reduce these avoidable costs and improve the health care of this population. It is clear that some of the proposed models are more or less likely to deliver a culture of integration and innovation. The Maryland Psychiatric Society believes that Maryland should ensure that the chosen model is hard-wired to contain the following features:

1. Financial rewards and penalties for the payor(s) should be integrated in such a manner that they are incentivized to coordinate services and prevent negative outcomes regardless of who is paying the bill. If the ASO denies a service and this results in an $80,000 bill to the MCO for hospitalization after a suicide attempt, the ASO should be at risk for part of this bill. Similarly, if the MBHO provides case management services that results in improved diabetes care management that leads to reduced hospitalization costs for the MCO, the MBHO should share in those savings. There should be no opportunities for one payor to point to the other payor and say “not me.”

2. Financial rewards and penalties for the clinicians should be integrated such that they are incentivized to pay attention to both somatic and behavioral health (BH) needs. This may include case management services that help behavioral health clinicians coordinate with somatic clinicians and services, as well as collaborative BH services that coordinate with PCPs.

3. Minimize administrative overhead such that the maximum proportion of expenditures are spent on direct care and coordination of services.

4. The spirit and letter of the Mental Health Parity and Addictions Equity Act should be proactively maintained. (There is a risk that a State-run ASO would be able to skirt the United States’s federal Mental Health Parity law, thus being able to provide less costly care to those with behavioral health problems than those with traditional MCO coverage. The Mental Health Parity law applies to Managed Care Organizations, not to states.) The payor must “provide a detailed analysis demonstrating that their utilization management protocols do not have more restrictive nonquantitative treatment limitations compared to those used on the somatic side. The term “protocol” includes “…any processes, strategies, evidentiary standards, or other factors used in applying the nonquantitative treatment limitation to mental health or substance use disorder benefits.”

5. If the organization delegates any of its responsibilities to another contracted organization, it must “specify that the contractor shall comply with, and maintain parity between the MH/SUD benefits it administers and the organization's medical/surgical benefits pursuant to the applicable federal and/or state law or regulation and any binding regulatory or subregulatory guidance related thereto.”

6. Descriptions of the processes that the organization uses to ensure compliance with regulatory health care parity requirements, including regulations pertaining to mental health and/or substance usage disorders (MHPAEA), including:

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