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Moving toward recovery and accountability

June 1, 2007
by JAMES GAVIN, MSW
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Factors stakeholders need to keep in mind as Medicaid faces increasing scrutiny

Medicaid plays a significant role in our country's healthcare delivery system. Today 53 million individuals have health insurance because of this vital federal/state program. For recipients with significant behavioral health issues, Medicaid coverage often has been the determining factor in their ability to access services essential to support their recovery.

Although often characterized as costly, Medicaid is an important part of the solution for increasing access to healthcare services. As state leaders wrestle with how to increase access to health insurance, they also must ensure that the best possible Medicaid program is in place. After all, just having insurance is insufficient to fully address healthcare needs. A truly effective delivery system allows individuals to participate in a continuum of well-organized, evidence-based supports and services. This consideration is crucially important when addressing the needs of those with mental illness and/or addiction.

As one of the largest (if not the largest) nonprofit behavioral health managed care companies in the country, Community Care Behavioral Health in Pittsburgh addresses Medicaid issues daily. Based on our experience, I recommend policy makers, providers, and stakeholders consider the following issues as they discuss moving Medicaid's behavioral health components toward greater accountability for access, quality of care, and financial performance.

The New Freedom Initiative and Recovery

Today's political and economic environments demand a renewed emphasis on stakeholder collaboration as the dominant feature in a system seeking balance between the demand for and availability of healthcare resources. The President's New Freedom Commission on Mental Health called for such collaboration and emphasized the power of recovery, setting the stage for states to begin thinking differently about how they support individuals with mental illness.

Community Care has demonstrated that using a recovery framework to manage behavioral health services not only respects an individual's unique needs, but also encourages using less costly peer-supported community-based services and improves quality of life. By effectively managing expensive services such as hospitalization, Community Care can pay for programs that members (i.e., consumers) want and that support recovery, such as peer-support services to assist those dealing with drug and alcohol addictions.

Community Care also has provided training programs to support the transformation of the delivery system to one that provides culturally competent, recovery-oriented services and supports. A series of annual conferences, called the Recovery Institute, creates the opportunity for providers, members, and other stakeholders to discuss the challenges and opportunities related to bringing recovery to the forefront of service planning and delivery.

Care Management

In its 2006 Profiles of Medicaid's High Cost Populations, the Kaiser Commission on Medicaid and the Uninsured identified individuals with mental illness as one of six high-cost populations requiring more effective support. The report reinforced the importance of ensuring that this population has access to an effectively managed service continuum to create a structured therapeutic environment that minimizes expensive inpatient admissions.

Community Care developed a clinical model for member care management that encourages oversight of decisions related to expensive services and helps providers and members identify appropriate community-based, recovery-oriented services and supports. Care management also establishes essential ongoing relationships with members with serious mental illness so that their immediate needs can be addressed quickly during a crisis.

The focus of our care management function ultimately is to ensure that members receive the appropriate level of care in the correct amount, frequency, and duration. Our successful use of care management can be attributed partly to our sophisticated information system. Using algorithms that consider prior authorization, utilization information, and other data elements, each member is rated on a severity scale. This allows care management resources to focus on members with the greatest needs.

Care Integration

We continue to learn more about the relationship between mental and physical health. Therefore, behavioral health and physical health professionals must work hard to create well-structured and respectful channels of communication. Relationships with corrections, social services, and vocational rehabilitation services also are essential.

Community Care has established and successfully sustained integrated relationships with physical health plans to exchange data and improve members' care. In addition to managing joint behavioral health and physical health pharmacy committees, Community Care also has collaborated with physical health plans to develop an integrated care management model allowing behavioral health and physical health managers to work side-by-side.

Evidence-Based Practices

Elected officials increasingly are focused on ensuring that investments in healthcare services be assessed routinely and that services be improved continually. This heightened accountability is important and should continue.

In response to increased performance expectations, behavioral health stakeholders must work together to transform the system by supporting the implementation of evidence-based practices (EBPs) and by building service agencies' capacity to effectively evaluate program outcomes. Pay-for-performance initiatives, as well as EBPs that provide clear guidelines for service delivery, need to be encouraged.

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