Integration effort seeks to streamline Medicaid

Five-year goals

Here are the five-year goals for the state innovation plan. Each goal has performance measures to evaluate progress and success.

o Healthy people and communities: By 2019, 80 percent of Washington residents and their communities will be healthier.

o Better care: By 2019, Medicaid clients with physical and behavioral co-morbidities (two or more chronic conditions or diseases) will have improved health outcomes and lower costs.

o Affordable care: By 2019, annual state-purchased health care cost growth will be 2 percent less than national health expenditure trend.

Currently in Clark County

Under the current Medicaid system, physical health, mental health and chemical dependency services are managed by different state agencies and regional organizations. Here is how the Medicaid services delivery system currently operates in Clark County:

Physical health: The state Health Care Authority oversees physical health care and low-level mental health services. The Health Care Authority contracts with managed care organizations, such as Columbia United Providers, Community Health Plan of Washington and Molina, which work with local physicians to provide medical care to Medicaid clients.

Mental health: For chronic, severe mental health services, the Department of Social and Health Services contracts with regional support networks, which contract with local providers. Southwest Washington Behavioral Health is the local network that covers Clark, Cowlitz and Skamania counties.

Outpatient chemical dependency: DSHS contracts with each county in the state to provide outpatient substance abuse services. In Clark County, the Community Services department manages the services and contracts with local providers.

Inpatient chemical dependency: DSHS manages inpatient substance abuse services through direct contracts with local providers.

John Smith enrolled in Medicaid after losing his job and, with it, his employer-provided health insurance.

He has chronic back problems and became addicted to the oxycodone his doctor prescribed to manage the pain. That addiction, coupled with his inability to afford his medication, led him to a heroin addiction.

He lost his apartment and is now staying in a shelter. The dramatic changes led to his depression — another condition going untreated.

John Smith’s scenario is a hypothetical. But it’s not unrealistic.

Clark County’s Medicaid population is often facing numerous health and social issues. In order to have their needs met, local health officials say Medicaid clients must navigate a complex state system with providers isolated in “silos” that thwart efforts to coordinate care.

In the hypothetical John Smith case, that means he could see different providers to address different issues, and those different providers don’t likely talk to each other about their shared patient. A physician seeing him for back pain might not know about his heroin addiction or depression.

But by April 2016, the pathway to health care — physical, mental and chemical dependency services — should be markedly easier. That’s when Southwest Washington is set to become one of three regions in the state with fully integrated Medicaid services and a collaborative process in place to address the social issues that impact a person’s health.

The goals are better health outcomes, better care and lower health care costs.

“If we really are going to achieve the triple aim, we can’t continue to work in the siloed health care system,” said Dr. Alan Melnick, Clark County Public Health director. “When you’re seeing patients, especially the Medicaid population with high needs … it’s not really effective.

“Even though our health care system is siloed, our bodies aren’t siloed,” he added.

Coordinating care

Medicaid integration is a component of the Washington State Health Care Innovation Plan. The three overarching strategies of the plan are to build healthier communities that utilize community partners and promote prevention; transform health care compensation to center on how well the care works instead of just paying for the number of visits, tests or procedures; and better coordinate the care patients receive.

During the 2014 legislative session, the Legislature passed two bills that, in part, created regional service areas across the state and require full integration of the financing and delivery of Medicaid services by 2020.

“Currently, people on Medicaid have to navigate four different systems if they want to get help with medical, mental health and chemical dependency treatment,” said Vanessa Gaston, Clark County Community Services director.

In the current system, two state agencies — the Health Care Authority and the Department of Social and Health Services — oversee Medicaid services. The agencies contract with various regional organizations and health plans that, in turn, contract with local providers to serve Medicaid clients.

“These systems all have different access criteria and different assessments with clinicians not coordinating or even talking with each other,” Gaston said. “All of these barriers to access care have led to people falling through the cracks because they don’t know how to navigate these separate complex systems.”

Early adoption

The 10 regional service areas in the state had two choices to move toward Medicaid integration. They could first integrate mental health and chemical dependency services, creating what’s called Behavioral Health Organizations, by 2016 and then integrate physical health in 2020. Or regions could choose to be an early adopter and pursue full integration by April 2016.

Clark County commissioners decided in July to pursue early adoption, Gaston said. Skamania and Klickitat counties elected to join Clark County to form the Southwest Washington region.

This week, each county submitted their nonbinding letter of intent to the Health Care Authority.

Under the innovation plan’s early adopter model, the Health Care Authority will contract with health plans, which will administer all services — physical health, mental health and chemical dependency.

King and Pierce counties — both of which are single-county regions — have also opted to follow the early adopter model. The three early adopter regions represent roughly half of the state’s population, said Nathan Johnson, chief policy officer at the Health Care Authority.

Early adopters will not only set an example for full integration but also have the opportunity to benefit financially, Johnson said. The early adopter regions will receive a share of state savings generated through integration, he said.

The Health Care Authority is also working closely with community partners in each region to establish Accountable Communities of Health that will work with the health plans and providers to address the social issues impacting health. The Southwest Washington Regional Health Alliance intends to fill that role in this region.

Local alliance

In September 2009, Clark County teamed up with Cowlitz and Skamania counties to form the Southwest Washington Regional Health Alliance. The group includes representatives from the counties and a variety of community partners, including hospital systems, medical groups, health centers, social service organizations and health plans.

Since it’s inception, the alliance has explored ways to integrate Medicaid services. The counties recognized that, despite the amount of money being spent on services, clients were not getting the care and coordination they deserved, said Jon Hersen, board chairman and vice president of care transformation at Legacy Health.

“While the Medicaid system functions today, it doesn’t function as well as it could,” Hersen said. “A very fragile, high-need population in our community was being underserved.”

As an Accountable Community of Health, the alliance will serve as the link between the services delivery system and the social services and public health systems that can address the other issues impacting Medicaid clients’ health, such as housing, income and education. State and local health officials see that link as a crucial component of the innovation plan.

“You can’t improve people’s health or give them adequate health care if you’re not dealing with their social issues,” said Melnick, who is also an alliance board member.

If a person is homeless and struggling with substance abuse or mental health issues, managing their diabetes will be significantly more difficult, Melnick said.

“These things overlap and they’re synergistic,” he added.

Growing pains

The Medicaid system overhaul will likely come with some growing pains.

Integrating the services will rely on the different providers talking and working together — something that doesn’t traditionally happen now, Melnick said.

“A primary care provider may be seeing a person for 10 minutes about diabetes or asthma and have no idea about their mental health issues or substance abuse problems,” Melnick said.

Some local Medicaid service providers also have concerns about the integration.

“It sounds great in theory,” said Bunk Moren, executive director of Community Services Northwest, a mental health services provider. “Who can argue with that? I don’t think there’s a provider out there that would argue with that theoretical outcome. The devil is always in the detail.”

The early adopter approach will put the managed care plans, which don’t traditionally administer higher-level mental health services, in charge of funding those programs. In other parts of the country, that’s been done — sometimes successfully, sometimes not, Moren said.

“It can be done, but you’ve got to have providers and managed care entities that want to do it well,” he said.

Providers don’t want to see the current funding model dismantled without thoughtful review, Moren said. Doing so could have unintended consequences on the people everyone is trying to help — the patients, he said.

“I’m confident we’ll eventually get there,” Moren said. “I’m not confident we won’t get there without a period of a couple of years learning the hard way.”

Change underway

Some of the integration work has already begun in Southwest Washington.

In a fully integrated system, Southwest Washington Behavioral Health’s role will be eliminated, since managed care plans will administer mental health services. That means the service network will cease to exist, at least in its current capacity, in April 2016.

But in addition to continuing to coordinate services for Medicaid clients in the interim, Southwest Washington Behavioral Health is trying to help the counties, providers and health plans prepare for the transition, said Connie Mom-Chhing, chief executive officer of Southwest Washington Behavioral Health.

The organization’s staff is giving technical assistance to providers to ensure their infrastructure will be ready to integrate. They’re also trying to facilitate conversations between providers — connecting mental health, chemical dependency and physical health care providers — and working to educate health plans about the services they’ve provided, Mom-Chhing said.

Columbia United Providers, a Vancouver-based health plan that manages physical health care for about 50,000 Clark County Medicaid clients, spent the past six months working with Southwest Washington Behavioral Health to clear the legal barriers preventing the health plan and the network from sharing information. Columbia United Providers, which intends to submit a proposal to be an early adopter health plan, is also looking at how it may change its reimbursement rates to reflect the desired focus on value rather than volume and is soliciting feedback from its current providers, said Karen Lee, the plan’s chief executive officer.

Despite the significant amount of work that lies ahead, most agree the work is needed.

“Moving in the direction of early adoption accelerates the integration and collaboration that’s needed to better serve this community and the Medicaid participants in this community,” Hersen said.

“Continuing down the path we’ve been going is not good for anyone,” he added.