Hundreds of providers, administrators, government officials, consumers, and advocates attended a CHCF briefing last week to learn how Medicaid programs can integrate behavioral health services — mental health care and treatment of substance use disorder — and physical health care.

The February 18 event in Sacramento shared information about how Medicaid programs outside California approach the integration of physical and behavioral health, as well as what county-plan partnerships in California are working on. Many people think of integration as something that happens mainly at the clinical level, such as teaming physical care and behavioral care providers in the same location. But unless integration also occurs on the financial, operational, and administrative levels, it will be much harder to successfully provide integrated care.

Available Resources

Last year, CHCF and Well Being Trust published Behavioral Health Integration in Medi-Cal: A Blueprint for California. Building on that groundwork, CHCF supported other recent analyses, including:

• Making Integration Work: Key Elements for Effective Partnerships Between Physical and Behavioral Health Organizations in Medicaid from the Center for Health Care Strategies
• Paying for Value in Behavioral Health: What California Can Learn from Other States’ Medicaid Programs by Manatt, Phelps & Phillips
• Voluntary Behavioral Health Integration in Medi-Cal: What Can Be Achieved Under Current Law from the law firm Foley & Lardner

The briefing provided context for discussions of the draft plan for the state’s multiyear CalAIM (California Advancing and Innovating Medi-Cal) initiative. CalAIM includes several proposals that could help advance behavioral health integration and a proposal for local pilots that would integrate the full Medi-Cal benefit under one entity.

Right now, most Californians insured through Medi-Cal must navigate three separate systems of care — one for physical conditions such as diabetes, one for serious mental health issues such as schizophrenia, and another for substance use disorders like alcoholism.

Three Disconnected Systems of Care in Medi-Cal

These systems often do not communicate with one another about patients’ care, leading to poorly coordinated or duplicative services and worse outcomes. California’s system is unwieldy and challenging for patients and providers to navigate. It’s also not so different from systems in other states — many of which are moving to more integrated systems.

Different Places, Different Approaches

At the briefing, Allison Hamblin of the Center for Health Care Strategies outlined the range of approaches to integration (PDF) taken by other states. Washington and Arizona are among the states that have changed their systems to manage all Medicaid benefits under one accountable entity, Hamblin explained. In Arizona, which has specialty managed care plans designed specifically for people with serious behavioral health needs, the early findings are encouraging. Adults with serious mental illness showed improvement in all measures related to patient experience, ambulatory care, preventive care, and chronic disease management.

On a regional basis, Washington is rolling out fully integrated care through managed care plans for all Medicaid enrollees. Early results in one region show better access to treatment, as well as improvements in social measures such as homelessness and criminal justice interactions. These integration efforts are recent in most states, so much is yet to be learned.

Here in California, representatives of county governments and health plans told the briefing audience about progress and challenges in efforts to integrate services, operations, or financing. San Bernardino County’s Behavioral Health Department and the Inland Empire Health Plan are planning integration of primary care services with county mental health clinics at several sites. Representatives from San Mateo County Health described their work with the Health Plan of San Mateo to identify the best way to manage their mutual members. And Partnership HealthPlan of California is inching closer to managing the state’s substance use disorder benefit, known as the Drug Medi-Cal Organized Delivery System, in 8 of the 14 Northern California counties it serves.

Alice Washington, an associate with the California Institute for Behavioral Health Solutions, gave the briefing audience a consumer perspective. Alice said that, after she developed a serious mental illness in her late 20s, “physical health care fell off the radar,” and she developed diabetes as a result of her medication. She has “recovered to a place of wellness” due partly to the integrated physical and behavioral health care she receives and through her work with a cross-disciplinary care team.

Key Takeaways

A few lessons stood out from the briefing:

First, this work depends on relationships. Different systems have different languages, cultures, and expectations, and it takes time to achieve trust and learn to work together.

Second, it is hard, and it is time-consuming. But there are resources and models that can provide guidance.

Third, the state could make it easier for counties that want to work with local physical health providers and health plans to explore more efficient and productive ways to provide care for their shared members. These include providing guidance on data sharing and supporting efforts to integrate financing.

Fourth, consumers must be involved. Without their input into system design, integration can’t succeed.

CHCF will continue to share relevant research about how integration is working in Medicaid programs around the nation and how it could work in California.

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Catherine Teare

Catherine Teare is associate director of CHCF’s People-Centered Care team, which works to ensure that Californians — particularly those enrolled in Medi-Cal — receive responsive, comprehensive, and coordinated care that supports their health and well-being. She leads the foundation’s work on behavioral health care, including behavioral health integration in primary care and behavioral health interventions for high-cost populations. She also manages projects related to the county role in health care delivery and oral health care. Read More

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