Task force tackles integration of behavioral health, primary care

After months of collecting input, a Massachusetts task force is developing recommendations for the integration of behavioral health (mental health and substance use) and primary care for adults, children and families, within the context of service delivery strategies and payment reforms. The goal is to improve access and outcomes for those who face mental illness or substance issues.

The nation is undergoing significant health care reform under 2010’s Affordable Care Act, modeled after Massachusetts’ 2006 health care insurance reform law. Massachusetts entered the next chapter in health care reform with the adoption of Chapter 224 of the Acts of 2012, which focuses on improving the quality and efficiency of health care delivery and payment systems, including the integration of primary care with behavioral health.

Among items in Chapter 224 was creation of the Behavioral Health Integration Task Force, chaired by Department of Mental Health Commissioner Marcia Fowler, M.A., J.D and including 19 stakeholders from the behavioral health community.

“We’re really at part two of health care reform,” Fowler says. “I think the rest of the country is doing part one, which is a getting everybody insured. We are at part two, which is looking at two things – improving quality and health outcomes and controlling costs.”

Following months of input from consumers, providers, clinicians and advocates, the task force developed integration recommendations and was scheduled to submit its report to the Legislature and the newly created Health Policy Commission by July 1.

Among issues the task force reviewed:

• Effective and appropriate approaches to including behavioral, substance use and mental health disorder services in the array of services provided by provider organizations;

• Reimbursement methods that may need to be modified to achieve more cost-effective, integrated and high-quality outcomes;

• The extent to which and how payment for behavioral health services should be included under alternative payment methodologies, including how to achieve mental health parity;

• How best to educate providers to recognize behavioral health conditions and make appropriate referrals; and on the effects of cardiovascular disease, diabetes, and obesity on patients with serious mental illness; and

• The unique privacy factors required for the integration of information into interoperable electronic health records.

Following a request for information and two March public forums, the task force gathered thousands of pages of feedback based on a specific set of questions from the Legislature to help guide its recommendations.

“We looked at clinical models of integration and there is no one preferred clinical model,” Fowler says. “You are really looking at health care delivered in a variety of settings such as hospitals and large physician practices. The focus is really looking at having a cross-trained workforce of mental health professionals who are trained in interacting and talking with health care professionals and vice versa.”

Fowler says people with behavioral health disorders are among those who drive up health costs, but not because of treatment. “It’s the chronic physical health conditions of those with behavioral health disorders that are the significant health drivers.”

In drafting recommendations, one of the key drivers is looking at alternative payments methodology. “Fee-for-service payment methodology is really a significant cost driver,” Fowler says. “It’s really volume-based – it’s not quality based at all.”

The task force also looked at parity issues. “With behavioral health treatment, you see the need for prior authorization in many more cases than in physical care and a real inadequacy in rates for services. So we’ll be looking at parity for both.” she says.

Fowler is optimistic that integration will improve outcomes among children. About 50 percent of mental illness presents itself prior to age 14 and 70 percent before age 24, she says. “We really have an opportunity to focus on prevention activities and early intervention. We have high hopes for interrupting the trajectory of mental illness and of preventing chronic disabling illnesses that we see in our adult population.”

Fowler notes that one recommendation involves reimbursement for behavioral health screening for all children, not just those currently covered by MassHealth. The task force wants commercial plans to broaden coverage beyond a doctor’s visit or hospitalization.

The task force is also considering a tier approach for dealing with integrated electronic medical records that uses an opt-in/opt-out method, according to Fowler.