Better integrating primary care, behavioral health care and related healthcare services was key to the Affordable Care Act’s strategy to achieve a transformed system.
Over nearly the past decade, more than 30 states are either pending, approved for or have completed a federal Section 1115 waiver providing for five years of investment in major Medicaid delivery system reforms, involving projects targeting improvements in population health strategies and varying methods for driving up healthcare quality while reducing unnecessary costs.
Beyond Medicaid transformation projects, myriad practice transformation networks involving states, managed care organizations, professional member groups, charitable organizations and a host of community stakeholder partners have crafted methods to better care for people in ways that shift the total system of care from a largely siloed model to an increasingly shared-risk systemic model with greater patient access, control and outcomes.
Washington State is in the midst of major structural integration at the contract, governmental, regulatory and care delivery levels of healthcare.
This step opened the door for integrating behavioral health and medical service contracts between the state and managed care organizations — part of a “value-based purchasing” strategy — and, presumably in the years to follow, even beyond the continuum of physical and behavioral health care.
On Jan. 1, 2018, my region — north-central Washington — became the second of nine healthcare regions in the state to achieve a fully integrated managed care (IMC) contract transition. Six regions will become IMC regions in 2019, and the remaining region will transition Jan. 1, 2020.
This massive, statewide transition from a centralized, regional and county-driven behavioral healthcare authority in nine regions to having multiple competing, privately managed care organizations (MCOs) in each region integrate physical and behavioral health coverage for all Medicaid recipients is a major change in the way healthcare is purchased at the state level and implemented at the regional level. It is expected to reshape contracting with healthcare organizations in significant ways over the next few years — notably, through new, as-yet-under-defined value-based payment contract elements.
These shifts in goals from the Centers for Medicare & Medicaid Services (CMS) did not originate in the Medicaid program. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 had supported and continues to support Medicare’s acceleration of value-based purchasing. Medicare has paved pathways through alternative payment models (APMs) that began this year. One example of this is CMS’ Hospital Value-Based Purchasing program, in which Medicare’s payment system rewards providers for the quality of care by adjusting payments to hospitals under the Inpatient Prospective Payment System (IPPS) based on the quality of care delivered.
With Medicare ahead of Medicaid’s learning curve and far more streamlined, many point to these Medicare reforms as a relatively simplified — some might say oversimplified — blueprint for the more-complex Medicaid delivery system.
The Washington State Health Care Authority (HCA) is at the helm of Medicaid managed care expeditions into APMs in the Evergreen State. In compliance with 2SSB 6312, the HCA has been working to transform the Medicaid managed care delivery system and has pledged that 90% of HCA provider payments under state-financed healthcare programs — Apple Health (Medicaid) and the Employee and Retirees Benefits (ERB) programs (comprising the Public Employees Benefits Board [PEBB] and School Employees Benefits Board [SEBB] programs) — will be linked to quality and value by 2021. Some have criticized the “squishy” nature of this 90% commitment, yet no one questions the goal: to see an adjusted annual healthcare cost growth curve in Washington State lower than the national health expenditures trend.
One of five targeted areas for investment, supported by 16% of SIM funds, was the establishment of nine Accountable Communities of Health (ACHs), one in each healthcare region, convening bodies tasked with implementing the plans for population health projects; linking a broad base of community partners with healthcare practice transformation efforts; and enhancing data collection to adjust for local costs, quality factors and utilization trends and needs.
ACHs have been the cornerstone SIM investment in Washington State, local base camps for exploration into new frontiers of innovation at the level of contracting and payment redesign and practice transformation on the front lines of care, as well as significant shifts in strategy at every level in the way we engage in health systems analytics, interoperability and measurement.
My work in these efforts began with my regional ACH, which was established in 2015 through our ACH-driven, initially SIM-funded Whole Person Care Collaborative, a convening of regional, multidisciplinary healthcare providers working to understand the new terms and the changing landscape.
These rule changes eliminated duplicative and inefficient documentation and assessment requirements, attempting to better streamline service delivery and improve access to care.
The state also adjusted the definition of “mental health professional” to provide for much-needed flexibility and structure to meet the differing needs of agencies and improve access to care, eliminated some of the prescriptive training requirements on agencies to allow for more tailored approaches and paved the way for agencies to apply for documentation exemptions when their innovative approaches follow an evidence-based, research-based or state-mandated program that provides adequate protection for patient safety.
Then on July 1, 2018, at the direction of state law, DBHR was dissolved. Staffing and responsibilities for licensing and certification of mental health, SUD and problem gambling treatment programs were then transferred to the Department of Health’s Health Systems Quality Assurance (DOH-HSQA) program, while staffing and responsibilities for behavioral health rulemaking were transferred to the state HCA and the DOH. That consolidated chapter of behavioral health regulation was then integrated with DOH rules for behavioral health to form, again, a newly revised set of regulations for behavioral health, all part of progressive efforts to integrate physical and behavioral healthcare at the levels of state government and regulation.
Four goals of the statewide transformation project include reducing avoidable use of intensive services and settings, improving population health, accelerating the transition to value-based payment and ensuring that per-capita cost growth is below national trends. Each of Washington State’s nine regional ACHs were required to adopt a minimum of four projects from a statewide toolkit, with two projects being mandatory for all nine regions: one focusing on increasing and enhancing bidirectional integration of physical and behavioral healthcare, and the other focusing on addressing the state’s opioid crisis. In the north-central region, we chose six: adopting elective toolkit projects focused on chronic disease prevention and control, diversion interventions to reduce unnecessary acute care, improving transitions from acute to outpatient care, community-based care coordination and social determinants of health.
We all recognize that a person’s state of health is influenced by much more than the care he or she receives. Beyond healthcare, health is affected by genetics, environmental factors (such as housing, employment and other socioeconomic factors) and personal behaviors (such as diet, exercise and substance abuse). Whole-person care requires us to pay attention to and address all these factors more effectively, connecting patients with resources outside the clinic and thereby addressing “non-clinical” social determinants of health. Whole-person care also mitigates the dividedness between behavioral healthcare and medical care.
In addition to providing specialty behavioral healthcare, including psychotherapy, psychological testing and psychiatric medication management, Columbia Valley Community Health also has 10 behavioral health providers embedded within our primary care and express care clinics who work closely alongside medical providers in the daily patient flow to increase access and enhance timeliness and effectiveness of care provided through an integrated care approach. Our state’s vision of whole-person care is for a patient to reach a condition of physical, mental and social well-being by creating a robust, integrated communitywide system of care that enhances the patient experience of care, improves the health of our citizens and population overall and reduces the per-capita cost of healthcare.
Over nearly the past decade, more than 30 states are either pending, approved for or have completed a federal Section 1115 waiver providing for five years of investment in major Medicaid delivery system reforms, involving projects targeting improvements in population health strategies and varying methods for driving up healthcare quality while reducing unnecessary costs.
Beyond Medicaid transformation projects, myriad practice transformation networks involving states, managed care organizations, professional member groups, charitable organizations and a host of community stakeholder partners have crafted methods to better care for people in ways that shift the total system of care from a largely siloed model to an increasingly shared-risk systemic model with greater patient access, control and outcomes.
Washington State is in the midst of major structural integration at the contract, governmental, regulatory and care delivery levels of healthcare.
Contract-level managed care integration
In 2014, a new law passed, requiring full integration of behavioral health benefits into the state’s Medicaid managed care program, Apple Health, by 2020. This provided a high-level road map for managed care contract integration that resulted, first, in transitioning from a regional county-driven model — which maintained a firewall between mental health and substance use disorder treatment contracting — to a privatized, managed care model in 2016, which integrates mental health and substance use disorder (SUD) treatment contracts.This step opened the door for integrating behavioral health and medical service contracts between the state and managed care organizations — part of a “value-based purchasing” strategy — and, presumably in the years to follow, even beyond the continuum of physical and behavioral health care.
On Jan. 1, 2018, my region — north-central Washington — became the second of nine healthcare regions in the state to achieve a fully integrated managed care (IMC) contract transition. Six regions will become IMC regions in 2019, and the remaining region will transition Jan. 1, 2020.
This massive, statewide transition from a centralized, regional and county-driven behavioral healthcare authority in nine regions to having multiple competing, privately managed care organizations (MCOs) in each region integrate physical and behavioral health coverage for all Medicaid recipients is a major change in the way healthcare is purchased at the state level and implemented at the regional level. It is expected to reshape contracting with healthcare organizations in significant ways over the next few years — notably, through new, as-yet-under-defined value-based payment contract elements.
These shifts in goals from the Centers for Medicare & Medicaid Services (CMS) did not originate in the Medicaid program. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 had supported and continues to support Medicare’s acceleration of value-based purchasing. Medicare has paved pathways through alternative payment models (APMs) that began this year. One example of this is CMS’ Hospital Value-Based Purchasing program, in which Medicare’s payment system rewards providers for the quality of care by adjusting payments to hospitals under the Inpatient Prospective Payment System (IPPS) based on the quality of care delivered.
With Medicare ahead of Medicaid’s learning curve and far more streamlined, many point to these Medicare reforms as a relatively simplified — some might say oversimplified — blueprint for the more-complex Medicaid delivery system.
The Washington State Health Care Authority (HCA) is at the helm of Medicaid managed care expeditions into APMs in the Evergreen State. In compliance with 2SSB 6312, the HCA has been working to transform the Medicaid managed care delivery system and has pledged that 90% of HCA provider payments under state-financed healthcare programs — Apple Health (Medicaid) and the Employee and Retirees Benefits (ERB) programs (comprising the Public Employees Benefits Board [PEBB] and School Employees Benefits Board [SEBB] programs) — will be linked to quality and value by 2021. Some have criticized the “squishy” nature of this 90% commitment, yet no one questions the goal: to see an adjusted annual healthcare cost growth curve in Washington State lower than the national health expenditures trend.
Accountable communities of health
Washington State has just completed the final year of a five-year, $65-million grant from the Center for Medicare & Medicaid Innovation’s (CMMI) State Innovation Models (SIM) program. Over that time, the SIM grant supported significant shifts in emphasis, at the governmental level and in infrastructure and initiatives throughout the state, toward innovative population health approaches to care, innovative payment designs that reward value and improvements in models of integration between physical healthcare, mental healthcare and SUD treatment.One of five targeted areas for investment, supported by 16% of SIM funds, was the establishment of nine Accountable Communities of Health (ACHs), one in each healthcare region, convening bodies tasked with implementing the plans for population health projects; linking a broad base of community partners with healthcare practice transformation efforts; and enhancing data collection to adjust for local costs, quality factors and utilization trends and needs.
ACHs have been the cornerstone SIM investment in Washington State, local base camps for exploration into new frontiers of innovation at the level of contracting and payment redesign and practice transformation on the front lines of care, as well as significant shifts in strategy at every level in the way we engage in health systems analytics, interoperability and measurement.
My work in these efforts began with my regional ACH, which was established in 2015 through our ACH-driven, initially SIM-funded Whole Person Care Collaborative, a convening of regional, multidisciplinary healthcare providers working to understand the new terms and the changing landscape.
Eliminating barriers to care delivery redesign
In early 2018, the state began a rapid process of merging, consolidating and streamlining behavioral health regulations and governmental oversight to maximize efficiencies and reduce costs. On April 1, 2018, Washington State’s Department of Social and Health Services (DSHS) Division of Behavioral Health and Recovery (DBHR) consolidated five Washington Administrative Code (WAC) chapters regulating behavioral health into one, merging regulatory framework and language for mental health treatments, SUD treatment, co-occurring treatment and pathological gambling treatment.These rule changes eliminated duplicative and inefficient documentation and assessment requirements, attempting to better streamline service delivery and improve access to care.
The state also adjusted the definition of “mental health professional” to provide for much-needed flexibility and structure to meet the differing needs of agencies and improve access to care, eliminated some of the prescriptive training requirements on agencies to allow for more tailored approaches and paved the way for agencies to apply for documentation exemptions when their innovative approaches follow an evidence-based, research-based or state-mandated program that provides adequate protection for patient safety.
Then on July 1, 2018, at the direction of state law, DBHR was dissolved. Staffing and responsibilities for licensing and certification of mental health, SUD and problem gambling treatment programs were then transferred to the Department of Health’s Health Systems Quality Assurance (DOH-HSQA) program, while staffing and responsibilities for behavioral health rulemaking were transferred to the state HCA and the DOH. That consolidated chapter of behavioral health regulation was then integrated with DOH rules for behavioral health to form, again, a newly revised set of regulations for behavioral health, all part of progressive efforts to integrate physical and behavioral healthcare at the levels of state government and regulation.
Collective, systemic value transformation
The contract, governmental and regulatory changes all had a larger purpose: transforming the care delivery system. In response to the state’s application for a federal Section 1115 demonstration project waiver in January 2017, the State of Washington reached an agreement with CMS and was approved for a five-year, $1.5-billion Medicaid Demonstration Project affording the opportunity for comprehensive Medicaid delivery and payment reform through the Delivery System Reform Incentive Payment (DSRIP) program. DSRIP has provided an instrument for incentivizing and rewarding regionally based care redesign approaches that promote clinical and community linkages, particularly those that better integrate physical and behavioral healthcare, address social determinants of health, and progress “whole-person” and value-based healthcare.Four goals of the statewide transformation project include reducing avoidable use of intensive services and settings, improving population health, accelerating the transition to value-based payment and ensuring that per-capita cost growth is below national trends. Each of Washington State’s nine regional ACHs were required to adopt a minimum of four projects from a statewide toolkit, with two projects being mandatory for all nine regions: one focusing on increasing and enhancing bidirectional integration of physical and behavioral healthcare, and the other focusing on addressing the state’s opioid crisis. In the north-central region, we chose six: adopting elective toolkit projects focused on chronic disease prevention and control, diversion interventions to reduce unnecessary acute care, improving transitions from acute to outpatient care, community-based care coordination and social determinants of health.
We all recognize that a person’s state of health is influenced by much more than the care he or she receives. Beyond healthcare, health is affected by genetics, environmental factors (such as housing, employment and other socioeconomic factors) and personal behaviors (such as diet, exercise and substance abuse). Whole-person care requires us to pay attention to and address all these factors more effectively, connecting patients with resources outside the clinic and thereby addressing “non-clinical” social determinants of health. Whole-person care also mitigates the dividedness between behavioral healthcare and medical care.
In addition to providing specialty behavioral healthcare, including psychotherapy, psychological testing and psychiatric medication management, Columbia Valley Community Health also has 10 behavioral health providers embedded within our primary care and express care clinics who work closely alongside medical providers in the daily patient flow to increase access and enhance timeliness and effectiveness of care provided through an integrated care approach. Our state’s vision of whole-person care is for a patient to reach a condition of physical, mental and social well-being by creating a robust, integrated communitywide system of care that enhances the patient experience of care, improves the health of our citizens and population overall and reduces the per-capita cost of healthcare.
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