Quantifying Integrated Physical and Behavioral Health Care in Medi-Cal

Many adult Medi-Cal enrollees require care from multiple systems. People receive physical health services and mental health services for low acuity (“mild-to-moderate”) conditions from Medi-Cal managed care plans. County mental health plans provide specialty mental health services for serious mental illness, and county Drug Medi-Cal programs provide treatment for substance use disorders.

People Who Need Both Physical and Behavioral Health Care

People with serious mental illness and substance use disorders are at greater risk of physical illnesses including obesity, diabetes, and cardiovascular disease.¹ Despite this increased risk, they are less likely to receive routine primary care.² Social instability, motivation challenges, fearfulness, and stigma may all make it more difficult for people with serious mental illness to seek out physical health care, and accessing care in siloed systems can be particularly challenging because many of these patients require intensive coordination, outreach, engagement, clinical information sharing, medication reconciliation, and patient and family engagement.³

Unfortunately, we understand very little about how well the Medi-Cal program meets the needs of patients requiring care across these multiple systems. Managed care plans and county systems do not regularly exchange information about the patients they share. Providers in the various systems frequently complain that they do not know what kind of care their patients are receiving from other systems, including that someone in their care has been hospitalized. Medi-Cal enrollees themselves may face health risks if their primary care provider is not aware of their psychiatric prescriptions, for example. At the county and statewide levels, there is no comprehensive effort to assess the health outcomes of people who receive Medi-Cal services from multiple systems and who stand to benefit from improved integration efforts.

While several current Medi-Cal efforts, including the Whole Person Care pilots and Health Homes Program, are aimed at addressing these care integration challenges for specific populations of members, there is no comprehensive approach to measuring the impact of these integration efforts. It does not have to be this way.

Available Measures

Even in the current siloed system, there are some avenues by which to measure care across systems. In consultation with stakeholders and experts, the Blue Sky Consulting Group has identified a set of valid and reliable measures that managed care plans, county mental health plans, and county substance use disorder programs can collect, track, and use. With these measures, programs can quantify and monitor health outcomes for people who access (or should access) care across multiple systems — outcomes likely to be affected by the integration of care across systems.

Even in the current siloed system, there are some avenues by which to measure care across systems.

These measures are described in a table that provides specifications for each measure, including how to construct the measure, suggested comparison groups, and an assessment of the feasibility of implementation. The table is available under Document Downloads in two formats: a static version (PDF) and a sortable Excel spreadsheet (ZIP).

Most of these measures rely on existing data sources. Many are based on Healthcare Effectiveness Data and Information Set (HEDIS) measures, such as those in California’s Department of Health Care Services (DHCS) External Accountability Set, that are already collected by DHCS and by managed care plans, and/or by counties.

Among the questions that could be answered based on this measurement resource are:

1. What percentage of adult Medi-Cal managed care members who are receiving specialty mental health or substance use disorder services had a primary care visit in the past year?
2. What is the emergency department visit rate for adult members receiving specialty mental health or substance use disorder services in the past year?
3. What percentage of adult members receiving specialty mental health services receive screening for diabetes and cancer?

The measures come from the Substance Abuse and Mental Health Services Administration (SAMHSA), Agency for Healthcare Research and Quality (AHRQ), and National Quality Forum (NQF) as well as peer-reviewed literature on prevalent comorbidities among people with serious mental illness and/or substance use disorder. Blue Sky Consulting Group also conducted interviews with leaders at managed care plans, mental health plans, and other experts.

Using the Resource

On the local level, the first step in putting this measurement resource to use would be for managed care plans and county mental health plans to jointly select a set of priority measures, based on local conditions and data access, to establish an integration baseline. From there, progress can be assessed over time. County behavioral health departments and managed care plans can measure performance, compare their performance to similar communities, and assess the effectiveness of efforts to improve care integration.

On the state level, DHCS could construct a set of measures that are both feasible and of broad interest, and then make this information available to local stakeholders across the state. By using the measures collected in this resource, local communities and DHCS can begin to measure care across systems, with the goal of improving integration and health care outcomes for affected populations.

Why Measurement Matters

Addressing adult Medi-Cal enrollees’ physical and behavioral health needs seamlessly and collaboratively is important because this population experiences co-occurring physical health, mental health, and substance use issues at high rates. This resource offers plans, counties, the Department of Health Care Services, and others a clear path to assess and improve the delivery of services for a population with complex needs.

Notes

1. “Physical Health Conditions Among Adults with Mental Illnesses [PDF],” The NSDUH Report, April 5, 2012; and Cynthia Boyd et al., Clarifying Multimorbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid Populations, Center for Health Care Strategies, December 2010. ↩︎
2. Benjamin G. Druss and Silke A. von Esenwein, “Improving General Medical Care for Persons with Mental and Addictive Disorders: Systematic Review,” General Hospital Psychiatry 28, no. 2 (March–April 2006): 145–53, doi:10.1016/j.genhosppsych.2005.10.006. ↩︎
3. Len Finocchio, Katrina Connolly, and Matthew Newman, Improving Mental Health Services Integration in Medi-Cal: Strategies for Consideration, Blue Shield of California Foundation, May 2017. ↩︎