Logan Kelly, MPH

July 2, 2019

In California, like many states, fragmented systems for delivering physical and behavioral health care for Medicaid beneficiaries often lead to access barriers, care disruptions, and a lack of care coordination – in many cases, resulting in poor health outcomes and high costs. To address this disconnect, the California Health Care Foundation (CHCF) recently released the Behavioral Health Integration in Medi-Cal: A Blueprint for California, a set of nine ambitious recommendations for achieving a transformative goal:

By 2025, all Medi-Cal enrollees will experience high-quality, integrated care for physical health, mental health, and substance use needs, with all of an individual’s care managed by a single entity accountable for payment, administration, and oversight.

Many Medi-Cal enrollees with serious behavioral health needs currently receive care that is managed by multiple entities: managed care plans for physical health as well as non-specialty behavioral health services; county mental health plans for specialty mental health services; and county alcohol and drug programs for substance use disorder services. CHCF’s Behavioral Health Integration Blueprint outlines a bold call for systems-level change to address this fragmentation. The first recommendation in the Blueprint proposes that California assign responsibility for all physical and behavioral health services to Medi-Cal managed care plans, while allowing delegation to interested counties and/or regions to the extent that such partnerships meet a single statewide standard for integration, quality of care, and accountability. Recommendations also identify financing and payment changes, implementation sequencing, and stakeholder engagement opportunities to support integrated care.

These Blueprint recommendations were formulated through a strategic stakeholder process. While the Blueprint itself is specific to California’s unique delivery system and complex county-state relationships, many of the steps taken to develop this consensus set of recommendations offer lessons for other states seeking to align stakeholders to address the shortcomings of physical and behavioral health fragmentation.

Developing a new vision for strategic policy challenges

Nationally, efforts to integrate physical and behavioral health care often stall or are limited by the complexities of behavioral health funding and the daunting challenges in considering system redesign. To overcome these roadblocks, the California Health Care Foundation and Well Being Trust brought together a work group of leaders with deep expertise in and diverse perspectives on California’s behavioral health system, including those with experience in provider organizations, county behavioral health departments, managed care plans, state agencies, and consumer advocacy. Importantly, these leaders were invited to participate as individuals representing their own perspectives rather than their specific organizational interests. The California Health Care Foundation and Well Being Trust engaged the Center for Health Care Strategies, in partnership with Steve Kaplan Consulting, to facilitate a work group that met in person three times, and develop a written blueprint for change.

Together, we undertook the following deliberate and collaborative steps to incubate an enrollee-centered vision and universally endorsed recommendations:

1. Articulate shared guiding principles for how a redesigned system would impact Medi-Cal enrollees and families with behavioral health needs.

The work group emphasized that enrollees should experience a high-quality, well-coordinated, and person-centered continuum of care from prevention to recovery services, with a system that advances health equity.

2. Examine other state efforts to confront similar challenges in their Medicaid programs.

We brought in leaders from states that pursued very different approaches to share insights on design and implementation considerations with the work group, and analyzed the national landscape around behavioral health integration, including emerging evidence on outcomes from innovator states such as Arizona and Washington.

3. Invite diverse experts in California’s behavioral health system to consider the merits and challenges of bold pathways toward integration.

We interviewed a broad group of stakeholders from providers, county behavioral health departments, and managed care plans to reflect on the current system as well as multiple options to pursue integration. Then, we synthesized these perspectives to inform the work group’s in-depth exploration of these different pathways.

4. Identify high-level strategies to advance integration within the varied, nuanced policy and funding contexts of California’s unique managed care environment.

The work group considered how to most effectively structure integration efforts within the complex landscape of behavioral health funding, administration, and delivery in California, and focused on how to build on the investments and strengths in the current system while developing a new system that incentivizes coordinated, value-based, and preventive care.

5. Consider opportunities to sequence integration efforts.

The work group identified specific steps in a phased approach to advance statewide integration of physical and behavioral health, along with immediate and longer-term changes that may be required at the county, state, and federal level, and grounded recommendations in a nuanced understanding of the funding and policy considerations facing state and county leaders.

6. Explore how to enable county-by-county variation within a single statewide standard for accountability.

Finally, the work group carefully considered how to enable adaptive models for California’s 58 counties while ensuring that Medi-Cal enrollees experience the benefits of integrated clinical care – across all care settings, and across the continuum of need.

The elements of this process may be helpful for other states pursuing similar initiatives to address “third rail” policy issues, including but not limited to physical-behavioral health integration.

Seizing opportunities and looking ahead

Behavioral Health Integration in Medi-Cal: A Blueprint for California is intended to catalyze thoughtful consideration — and action— among those who confront the challenges of the current siloed system in California every day. Providers, consumers, counties, health plans, and policymakers all understand the stakes of this issue for the future of the state. As key Section 1915(b) and Section 1115 waivers in California expire in 2020, and as the new gubernatorial administration is shaping an agenda for the next era of behavioral health care, these recommendations demonstrate how California can become a national leader in improving care for people with behavioral health needs.

Stakeholders in other states are also grappling with these issues, and in recent years, a number of states have pursued physical-behavioral health integration, including through integrated managed care. California, as well as other states, will benefit from ongoing rigorous analysis of other state efforts and the evidence emerging from their implementation, while grounded in a goal and vision tailored for their unique state environments.

In particular, many states are interested in whether integrated financing of physical and behavioral health services leads to increased coordination — and ultimately, better health outcomes — for enrollees. A recently published CHCS issue brief interviewed providers in states that have implemented integrated Medicaid managed care programs to understand the on-the-ground experiences of providers in these systems, and identifies policy recommendations for states related to data-sharing, payment and business practices, and clinical service delivery to drive greater integration at the point of care.

The California-focused recommendations for physical/behavioral health integration dovetail with policy priorities relevant to many states, such as: (1) supporting a diverse and robust workforce to deliver integrated care across the full continuum of need; (2) incentivizing value-based payment models; and (3) fostering integrated physical and behavioral health care for individuals who are dually eligible for Medicare and Medicaid. Additional policy changes related to licensing reforms and information-sharing, among other issues, are also critically important to advancing integrated care.

Developing consensus around this ambitious vision represents an important milestone in tackling the challenges that have long impeded efforts to improve care delivery for Medi-Cal enrollees with complex behavioral health needs. These recommendations can help guide the path forward for California’ integration activities, and can also inform other state efforts to effectively align physical and behavioral health services for Medicaid beneficiaries across the nation.

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