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Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary (2015)

Chapter:3 Funding: Opportunities, Threats, and Potential for Innovation

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Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×

3

Funding: Opportunities, Threats, and Potential for Innovation

The first panel of the workshop looked at funding issues as a way of exploring the broader issues of health care reform. Funding provisions can serve either to isolate or to coordinate and integrate separate programs, many panelists noted. Program coordination and integration can in turn incorporate mental health care and prevention into such settings as pediatric practices, community health centers, and schools.

INTEGRATING SERVICES AT THE STATE LEVEL

Medicaid, together with the Children’s Health Insurance Program (CHIP), covers one in three children nationwide. It is a joint federal and state program, and states have significant flexibility to operate the program with federal approval. As a result, the health services delivered and the populations covered differ among states. Similarly, effective innovations differ among states in the context of health care delivery systems, marketplaces, and populations served.

The populations served by Medicaid tend to have a higher prevalence of some behavioral health conditions, such as ADHD, noted Lindsey Browning, a policy analyst with the National Association of Medicaid Directors, which represents the Medicaid directors of all 50 states, the District of Columbia, and U.S. territories. Medicaid also covers children with complex needs, such as children in foster care, former foster care children, and children with disabilities. Though less than 10 percent of children in Medicaid have behavioral health needs, they account for 38 percent of

Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×

Medicaid spending on children. “There is a real opportunity to drive value and to improve quality for this population of kids,” Browning said.

Medicaid directors across the country have been looking for ways to enhance value and promote delivery and payment reform in Medicaid, and behavioral health has been a focus because of the needs of the Medicaid population. According to the National Association of Medicaid Directors’ annual operations survey, all responding states (47) were involved in some kind of reform, nearly three-quarters of these directors are pursuing or implementing four or more reforms at once, and more than three-quarters of these states are focusing directly on behavioral health needs.

The ACA and new funding opportunities have accelerated these efforts, Browning said. For example, enhanced funding for health homes has benefited the population with behavioral health needs, she explained. As another example, Section 1115 waivers are supporting provider-level transformation, and increased funding for information technology systems is fostering interoperability and exchange of information. Such steps are a “key to driving integration and promoting coordination of care for kids,” Browning said.

Strategies for integration take place at three levels, Browning continued. The first is at the agency level, where integration builds linkages across systems of care that affect children. These linkages involve “not just Medicaid but child welfare, juvenile justice, the education system, and others.”

The second level of integration involves payments. States are finding new ways to link services that traditionally have been separate, where, for example, people had one insurance card for mental health needs and another insurance card for physical health needs.

The third level of integration involves health care providers. Integration can build linkages between providers to coordinate care and even integrate them into the same setting.

The fourth level of integration involves early intervention efforts for children. For some members of the population with behavioral health needs, Medicaid could end up covering them for the rest of their lives, Browning said. Early intervention creates an opportunity to improve quality, reduce costs, and, in some cases, keep people from needing the program indefinitely.

Prevention also faces challenges at the state level, Browning noted. Medicaid typically works under 1- or 2-year budget cycles, which produces pressure to reduce costs and save money in the short term. Also, legislators, providers, other stakeholders, and current beneficiaries who are focused on shaping the program for the population it currently serves can limit the ability to look upstream for value. Finally, a greater emphasis on prevention raises the question of who saves for prevention activities. “Medicaid is

Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×

accountable for its expenditures and its savings, but if the savings are going to, say, the education system or another agency, it is difficult to account for that.” Aligned leadership, including at the governor’s office, may be one way to help address this, said Browning.

PROMOTING INTEGRATION THROUGH THE INSURANCE SYSTEM

Mark Friedlander, chief medical officer for behavioral health for commercial plans at Aetna, noted that three-quarters of his job involves self-insured plan sponsors. Aetna is paid an administrative fee for these services, but his customers are mainly large corporations. These corporations are interested in value for money, paying for cost-effective services, and making a difference. Behavioral health is often viewed as an afterthought, Friedlander observed, but it is often a comorbidity of conditions that are significant cost drivers. The ACA is producing changes, so the question is how to leverage those changes to improve behavioral health.

The greatest opportunities on the commercial side are related to transforming the way that behavioral health services are delivered, said Friedlander, particularly at the practitioner level. To date, little has been done to evaluate the quality of services that are provided. In part, this is because private payers cannot tell the difference between the star providers and the duds. As he put it, “The claim comes in, and it looks exactly the same.” If a patient sees an outpatient provider for three sessions and then stops, has the patient been cured, or is the provider so bad that the patient has given up? “Our claims system cannot tell the difference.”

The ACA has put practitioners on notice that accountability is important. “Our efforts are aimed at reinforcing that message and identifying how to measure quality, how to reward and incentivize providers to deliver quality, and how to make sure that the services delivered are the appropriate services in the right quantities.” In many cases, providers want to do more of what they are comfortable doing. They prefer to operate in their own comfort zones rather than meet a patient’s most prominent needs. “That, too, provides a challenge for us in steering folks to the right resources for the right reasons.”

Another opportunity on the commercial side is to push behavioral health practitioners to go beyond their own silos. In recent decades, managed care organizations have helped to widen the division between medical and behavioral health. “We have the opportunity, through claims and through financial incentives, to push the behavioral health practitioners closer to the medical providers, particularly in primary care settings,” said Friedlander. Incentives can encourage behavioral health practitioners to work with primary care practices to assess and deliver brief services, such

Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×

as when child psychiatrists provide telephonic consultations to pediatricians. “It is slow going. There is a significant level of resistance, but that is the approach that we are taking at this stage. It may seem like baby steps compared to the system transformation that is needed, but that is where we have started.”

BEHAVIORAL HEALTH IN THE HEALTH CENTER PROGRAM

The Health Center Program under the Health Resources and Services Administration’s (HRSA’s) Bureau of Primary Health Care funds about 1,300 grantees across the nation that provide health care services to 1 in 15 citizens. As Olivia Shockey, the expansion division director under the bureau’s Office of Policy and Program Development, noted, the program targets the neediest, most underserved, and most vulnerable populations throughout the United States and in its territories.

As part of the ACA, the program has had the opportunity to offer funding for behavioral health integration to many of its grantees. Its grantees, which operate about 9,000 access points or health center sites across the nation, must provide referral to behavioral health care services, and about three-quarters provide more direct access to mental health and substance abuse services, not just referrals. Grants to more than 430 of the health centers supplement what they are already doing for behavioral health care and drive integrated services by bringing more providers onsite and through increased use of screening and brief interventions with patients, including youths. As a result of this behavioral health integration funding, which requires the addition of at least one new on-site provider and movement along the spectrum toward integrated care, the program expects the number of people receiving behavioral health services to increase.

The behavioral care initiatives are part of an array of opportunities created by the ACA allowing increased community-directed comprehensive primary health care services, which are the core of the Health Center Program, said Shockey. Grantees have been able to help more than 9 million people enroll in affordable health insurance coverage, which has been a great opportunity to advance health within the community. About 30 percent of all the health center patients are under the age of 18, with the bulk of those 12 and under.1

Funding under the ACA also has supported 43 Health Center–controlled networks to work with grantees to enhance their use of health information technology to drive care. Quality improvement awards to the health centers

______________

1HRSA Uniform Data System, available at: http://bphc.hrsa.gov/datareporting/index.html (accessed July 30, 2015).

Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×

have incentivized the use of electronic health records and the tracking and reporting of data, providing a better sense of performance.

INNOVATIONS THAT CAN PROMOTE INTEGRATION

Ellen-Marie Whelan, senior advisor at the Innovation Center of the Centers for Medicare & Medicaid Services (CMS) and acting chief population health officer for the CMS Center for Medicaid and CHIP Services, pointed to the growing trend of paying for value-based care, which “is where opportunities and threats clearly are as we look forward.” The Innovation Center has been funding many Medicare-driven, adult-focused programs, such as ACOs, bundled payments, and medical homes, but the organization has “started to evolve,” said Whelan. For example, it has been funding the Strong Start program to support prenatal care and decrease prematurity. Its large Partnerships for Patients program has been seeking to decrease hospital-acquired conditions, 1 of its 26 hospital engagement networks encompasses children’s hospitals, and it has been examining models created by practitioners to see if policies from CMS create barriers to those models.

CMS’s health care innovation awardees include pediatric providers, and it has sought to increase that number in round two of the health care innovation awards. Of the 17 states involved in state innovation models, 11 include activities in pediatrics, and many of these are looking at behavioral health. Furthermore, because the funding under state innovation models goes to governors’ offices, there is an opportunity for blended funding streams.

According to Whelan, the change from fee-for-service to paying for accountability is the biggest opportunity of the ACA. Fee-for-service inhibited integrated care, whereas integrated care involves many different team members, including parents and schools. Integrated care also helps address the problem, raised by a workshop participant, of pediatricians having too many things to do during a typical office visit. As the health care system moves away from a reliance on the fee-for-service model, teams rather than individuals will have both authority and accountability for care.

This change does beg the question of how to define accountability, she said, especially for measures that are outside the control of providers. Many approved measures are for healthy children, whereas a robust set of measures does not yet exist for children with behavioral health issues. Also, moving away from a fee-for-service system means moving away from claims data toward measuring interactions to demonstrate improved care. Some of these interactions are outside of the traditional medical system and include such measures as school readiness, school attendance, or housing

Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×

stability. What does accountability mean in the context of these measures, Whelan asked. This is a challenge in looking to see who is getting paid for doing what, what the outcomes are, and who is producing positive results.

Another issue that arose in discussion involves what should count as strong evidence. The models being pursued at the Innovation Center need an evidence base, Whelan said, but does that base consist only of randomized controlled trials, or are other forms of evidence acceptable? “What will the benchmark be?”

THE INTEGRATION OF BEHAVIORAL HEALTH AND PRIMARY CARE

A prominent topic of discussion among the panel and workshop participants involved the integration of physical and mental health. As McCabe pointed out, “The mind is not separated from the body, and yet, so many times at the state level, at the community level, at the practice level, it is.”

Browning observed that models of integration differ from state to state. What works in a Medicaid program with managed care is not going to work in a rural or frontier state with fee-for-service Medicaid. Even health homes, which are currently a prominent model to coordinate care, including care for behavioral health conditions, can look very different from place to place. In some, behavioral health providers are the locus of control, while in others control resides more with primary care providers.

A second model is managed care in which payments are integrated, Browning continued. Under a carve-out approach, behavioral health organizations and managed care organizations are accountable to coordinate services across health plans. Under a carve-in approach, one managed care organization delivers services for the population, providing for their complex needs and working to fulfill the coordination role.

A third model, which is more similar to the carve-in approach, involves the use of specialty plans. For example, a behavioral health plan could deliver all the services for people with significant and persistent mental illnesses. “This is a newer model, but I think it is interesting to see how that will work,” Browning said.

In all these approaches, states build mechanisms into the contract to hold health plans accountable for integrating services and evaluate the plans to make sure they are prepared to meet the needs of beneficiaries. For example, payment models such as retroactive payment bundles can hold providers accountable for integrating across care settings. This model can benchmark a provider’s performance on quality and cost and provides gain sharing or risk sharing based on comparisons with average performance.

Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×

“Payment models are starting to develop,” Browning said. “There are opportunities here, and we will see a variety of approaches that meet the particulars of a state’s Medicaid program.”

Freidlander pointed out that though things have changed, with separately managed behavioral health organizations, there sometimes exists among medical providers and behavioral health providers “That old mindset still remains in the provider community—that there is a risk that if a behavioral health diagnosis makes it onto a pediatrician’s claim, it is going to get rejected by the system, by the payer. That is not the case anymore, but I think that the urban myth still remains and makes things complicated, particularly if there is a carve-out environment.” He also pointed out that medical providers with additional training—in behavioral or developmental pediatrics, for example—may not be able to gain extra pay for that additional credential because general pediatricians are expected to be able to screen and provide basic services.

Friedlander noted that Aetna has started to connect behavioral health practitioners with large primary care practices. Unfortunately, success depends very much on the compatibility and behavior of those involved, he added. “We have seen some primary care practices resist intrusion into their space because it may tie up a revenue-generating consulting room. We have also seen behavioral health practitioners use the opportunity to offer services rent free but then provide interventions other than quick evaluations.”

Friedlander described another example of integrating behavioral health in other care settings in Aetna’s work to involve behavioral health practitioners in pain clinics, because many patients in these clinics not only have an underlying medical condition but also have dependence on controlled substances, underlying behavioral health conditions, or other issues that make their cases complicated and expensive.

To demonstrate the scale of undergoing efforts involving intergraded care, Shockey noted that in 2013 the health centers provided more than one million people with behavioral health care within the health centers themselves. An alternative to this form of integrated care is to provide grants for behavioral health providers, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), to have relationships with colocated or nearby primary care providers who receive grants from the Health Center Program.

As Whelan said, under the ACA, the Innovation Center can scale and spread successful models that improve outcomes and control costs. But, echoing Friedlander’s comment, she added that many of the existing models are driven by behavior. The federal government could help by providing or promoting the development and use of standards so that different models can themselves be integrated while retaining a measure of flexibility.

Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×

A final issue raised during the discussion of integration involves regulations for confidentiality and the sharing of records. Browning pointed out that regulations are strict around the sharing of data on treatment of substance use disorders, and states frequently cite these regulations as a major barrier to integration. The federal government is considering changes in these regulations, and the Medicaid directors support the sharing of all health information to enable integrated care.

METRICS AND MEASUREMENTS THAT CAN PROMOTE INTEGRATION

A second major focus of discussion during the panel was the creation and use of metrics and measurements that can promote integration. As Friedlander observed, “What does not get measured does not change,” but getting practitioners to make such measurements can be difficult. For example, coding is available as an incentive to track screening, but few practitioners have taken advantage of the opportunity.

Measures also need to make sense, Friedlander added. Things like screening and brief interventions for alcohol and drug use make a lot of sense. But the data showed that a significant percentage of the claims submitted for screening and brief interventions came from anesthesiologists. Prior to a surgical procedure, the anesthesiologist does an evaluation of the patient to assess their risks, and many were adding screening and brief interventions for alcohol use to their assessments. However, less than 1 percent of the people who were screened had subsequent claims for drug or alcohol treatment. Aetna would like the behavioral health community to do more screening to generate data and refine the measures that exist, he said.

Browning emphasized the quality of measures. High-quality measures should be able to look across populations to see if integration is taking place. Another opportunity is for alignment of high-quality measures of behavioral health integration across programs, which enhances the feasibility for providers, states, and health plans in reporting and collecting measures.

Shockey pointed out that in 2014 the National Quality Forum questionnaire, a behavioral health clinical performance measure focused on depression screening and treatment, was added to the health centers, and was one of many required clinical and financial performance measures.2 However, many other things could be measured. “We need to look at what needs to be added,” she said in response to a question about measures for youth behavioral health, noting that the new depression measure is for patients 12 and older.

______________

2Additional information on the National Quality Forum measures can be found at: https://www.qualityforum.org/Home.aspx (accessed July 30, 2015).

Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×

One risk is that measures can create incentives or disincentives for different interventions. For example, the Health Center Program has one measure of depression for adolescents 12 and up and a child health measure related to receiving appropriate immunizations by age 3, which leaves a gap for other children. “There are some areas that we might be able to improve or add measures as we look at children’s behavioral health,” Shockey said.

Whelan pointed to work being done on the development of measures by the National Institutes of Health (NIH), such as the Patient Reported Outcomes Measurement Information System (PROMIS), and other agencies of the Department of Health and Human Services. The PROMIS measures, for example, are patient-centered, Web-based, and free.3

______________

3Additional information on PROMIS can be found at: http://www.nihpromis.org (accessed July 30, 2015).

Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×

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Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×
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Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×
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Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×
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Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×
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Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×
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Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×
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Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×
Page29
Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×
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Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×
Page31
Suggested Citation:"3 Funding: Opportunities, Threats, and Potential for Innovation." National Academies of Sciences, Engineering, and Medicine. 2015. Opportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21795.
×
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The Patient Protection and Affordable Care Act (ACA), which was signed into law in 2010, has several provisions that could greatly improve the behavioral health of children and adolescents in the United States. It requires that many insurance plans cover mental health and substance use disorder services, rehabilitative services to help support people with behavioral health challenges, and preventive services like behavioral assessments for children and depression screening for adults. These and other provisions provide an opportunity to confront the many behavioral health challenges facing youth in America.

To explore how the ACA and other aspects of health care reform can support innovations to improve children's behavioral health and sustain those innovations over time, the Forum on Promoting Children's Cognitive, Affective, and Behavioral Health held a workshop on April 1-2, 2015. The workshop explicitly addressed the behavioral health needs of all children, including those with special health needs. It also took a two-generation approach, looking at the programs and services that support not only children but also parents and families. This report summarizes the presentations and discussions of this workshop.

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