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Global-pay model integrates behavioral health

October 20, 2014
by David Raths
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In western Colorado, community health workers are now providing non-medical support services such as grocery shopping or driving patients to physician appointments—tasks not reimbursed in a fee-for-service model, but beneficial for patients nonetheless. The new services are just a small example what’s different about Medicaid Prime, a two-year pilot launched in September that replaces the traditional fee-for-service model with comprehensive, population-based payments in seven participating counties.

Integrated care coupled with a global payment model has become a trend nationwide, and the Colorado participants expect to slow spending by 1.5 percent to 2 percent within two years over current Medicaid trends.

Behavioral health providers Mind Springs Health and Midwestern Colorado Mental Health Center are participating. Rocky Mountain Health Plans, a key local insurer is also onboard and serves as the regional care collaborative organization, providing risk based capital and bearing the insurance risk. The healthcare community has collectively assumed accountability for spending and will share in savings and downside losses. The effort is part of Colorado’s Accountable Care Collaborative program, a Medicaid initiative to shift a portion of the program’s fee-for-service population into an accountable care organization (ACO).

Under Medicaid Prime, Rocky Mountain Health Plans makes global payments to participating primary care practices and expects them to integrate behavioral health providers on their care teams.

“Behavioral health is critical for getting your arms around the total cost of health for any population, particularly the Medicaid population,” says Patrick Gordon, associate vice president of Rocky Mountain.

 Decades of managed care and disease management efforts by third parties that didn’t integrate behavioral health failed to move the needle, he says. Reducing costs hinges on the ability to address patient needs outside the scope of traditional clinical services.

“We need to address the behavioral and social determinants of health outcomes and work as far upstream as possible and slow the progression of disease and disability,” Gordon says. “We need to reduce the barriers to connect to people when they need it. That is the essence of this model.”

Sharing data

Sharon Raggio, president and CEO of Mind Springs, says the organization was looking forward to the chance to participate in the accountable care program because providers share in the savings.

“For us, it was a no-brainer,” she says. “We have held a belief that behaviors are the single biggest contributor to people’s poor health outcomes, which we can have an impact on. Who better than behavioral health to partner with physical health to make these differences?”

To participate in a communitywide accountable care effort, behavioral health providers need to be willing and able to share data about operations and costs with other participants in addition to patient data.  

“Sharing data was the core foundation to create a global budget and to understand where we could make an impact, not only in the health of individuals but also in savings from the healthcare business perspective,” Raggio says.

For example, one of the areas ripe for savings is overuse of emergency rooms. Amy Gallagher, director of integrated care for Mind Springs, says her mobile community health workers are assigned to specific primary care practices and focus on high-emergency room utilizers to help them with some of the psycho-social challenges that might be leading to the high ER utilization.

“These types of investments are incredibly important in serving this population, but we have been able to implement them with very conservative assumptions about the overall impact we expect collectively across all of our activities in the global budget,” Gordon says. “It is a matter of reducing trends by a couple points. That’s more than enough to get this off the ground.”

National implications

A recent report by the Commonwealth Fund notes that only 14 percent of ACOs have achieved complete or nearly complete integration with behavioral health providers.

Raggio says efforts to integrate behavioral health are happening across the country, but it will be a while before measured outcomes can be reported.

“I don’t think the detail or research is there yet to identify the best practices,” she says. “There are similar shared visions, outcomes and goals. We will have the opportunity to learn from each other.”