Integrated Care for adults wIth BehavIoral and PhysICal health needs: Issues & oPtIons

By: Dennis L. Kodner* November 2011

SUMMARY The integration of behavioral and physical health is viewed as the most logical way to provide comprehensive, whole person care in a quality, cost-effective manner. The need for integrated care is a particular concern for individuals with serious and complex behavioral health disorders; the population finds itself in fragmented systems of care with little or no coordination across providers. This often results in poor quality and higher costs. Medicaid, which is the biggest payer of behavioral health services and also covers a large share of publicly funded beneficiaries with mental disorders, chronic illness and physical disabilities, has the most to gain from pursuing integrated care solutions. The following paper presents the powerful rationale for integrating behavioral and physical health services and the important role of the primary care sector in this process. It also examines the various integrated care options available to the states to organize the financing and delivery of comprehensive services for Medicaid beneficiaries and dual eligible individuals at the highest levels of need. Finally, the requirements to achieve truly integrated care on the all-important clinical level are explored. This is the fourth in a series of papers that critically examine key policy and service delivery issues and options related to various special populations. The first paper looked at New York States People First Waiver for people with developmental disabilities from the perspective of Medicaid managed care.1 The second paper in the series focused on the dual eligible dilemma and the strategic implications for integrated models of care which bring together Medicare and Medicaid.2 The third paper examined the medical home model and its fit with various special needs populations.3

1 Kodner, D., New York States People First Waiver: Concept Paper on Strategic Issues and Options Related to the Development of Innovative Medicaid Managed Care Models for Developmentally Disabled Adults, Arthur Webb Group, Inc., n.d. 2 Kodner, D., Dual Eligibles: Understanding this Special Needs Population and Options to Improve Quality and Cost-Effectiveness of Care Through Integrated Solutions, Arthur Webb Group, Inc., September 2010 3 Kodner, D., The Medical Home: Improving Its Fit with the Frail Elderly and Other Special Needs Populations, Arthur Webb Group, Inc., October 2011.

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IntRodUctIon And BAckgRoUnd The historical practice of separating the provision of mental health and substance abuse services from physical health care is now considered misguided.4 This split, which is historic in its application, is especially a problem for people with chronic and severe behavioral health problems who require an array of coordinated services from both sides of the health system. The lack of integrated care with close links to primary care settings often leads to poor quality, higher costs, and other societal problems. As the federal government, the states, and leading-edge providers are seeking to transform health care and achieve more cost-effective publicly-funded care, more and more attention is being focused on developing managed and integrated care models for this complex population. This paper examines the issues and options related to this new and important direction against the backdrop of the enormous epidemiological, clinical, organizational, service delivery, financing, and policy challenges involved. Behavioral Health Challenges Behavioral health5 conditions not only impose a substantial burden on individuals and society, but are also highly prevalent and disabling. About one in four adultsan estimated 26 percent of Americans aged 18 and oldersuffer from these disorders.6 Although 60 million adults are afflicted with mental illness and/or substance abuse, the main illness burden is concentrated in the 6 percent of the population with serious and chronic mental health problems.7 Adults with so-called serious mental illness (SMI) and severe and persistent mental illness (SPMI)8 are moderately to severely impaired. They experience a wide range of problems in areas such as feeling, mood, and affect; thinking; turbulent family and interpersonal relationships; disruption in role performance; sociolegal problems; and, inability to care for themselves. Generally speaking, people with behavioral health problems frequently do not receive treatment.9 Fewer than 50 percent of all adults with such disorders do not receive the care they need.10 Moreover, behavioral health disorders often co-occur with other physical illnesses such as cardiovascular or pulmonary disease, diabetes, or arthritis; this complicates treatment and management, increases the level of disability, negatively affects outcomes, and raises the overall costs of medical care.11 Indeed, these mind-body exacerbations are a two-way street. Not only are behavioral health conditions often accompanied by physical comorbidities, but people suffering from chronic physical conditions like diabetes, stroke, and HIV/AIDS also experience relatively significant levels of depression and anxiety. This pattern leads to higher medical care
4 Agency for Healthcare Research and Quality (AHRQ), Integration of Mental Health/Substance Abuse and Primary Care, Evidence Report/Technology Assessment, AHRQ Publication No. 09-E003, October 2008. 5 The terms mental health and behavioral health are often used interchangeably. In this paper, we use the term behavioral health, which encompasses mental illness and substance abuse disorders. 6 Institute of Medicine, Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series, November 1, 2005. Available online at: http://www.iom.edu/Reports/2005?Improving-the-Quality-of-Health-Care-forMental-and-Substance-Use-Conditions-Quality-Chasm-Series.aspx. 7 Statistics, National Institute of Mental Health (NIMH). Available online at: http://www.nimh.nih.gov/health/topics/statistics/index.shtml 8 The SPMI category includes schizophrenia, bipolar disorder, other severe forms of depression, panic disorder, and obsessive-compulsive disorder. 9 AHRQ, 2008, op cit. 10 Russell, L., Mental Health Services in Primary Care: Tracking the Issue in the Context of Health Reform, Washington, DC: Center for American Progress, October 2010. 11 AHRQ, 2008, op cit.

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utilization and health care costs and ultimately affects patient outcomes.12 Overall, however, it the SMI and SPMI populations that are greatest risk of serious medical problems and shorter life spans.13 This is due, in large part, to the lack of access to preventive and primary care and the negative impact most of the effective psychotropic drugs have on physical health.14 It should be self-evident that people with chronic and serious behavioral health problems not only need excellent primary care, but also coordinated access to a wide range of mental health and substance abuse clinical services and supports. Financing of Behavioral Health Disorders The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that $100 billion was spent on behavioral health disorders in 2003.15 Publicly-funded outlays actually reached $58 billion in 2006.16 That is, public programs, including Medicaid, Medicare, and other federal, state and local sources, covered 58 percent of total costs. In 2008, the total economic costs for behavioral health were estimated at $317 billion or the equivalent of $1,000/year for every American.17 Medicaid is the largest payer of behavioral health services in the United States.18 In 2003, Medicaid paid 45 percent of all public expenditures.19 The Integrated Care Resource Center (ICRC), an initiative of the Centers for Medicare & Medicaid Services (CMS), recently presented the following profile of Medicaid and dual eligible beneficiaries with behavioral health conditions, including mental health and substance abuse disorders20: X Over half of Medicaid beneficiaries with disabilities have been diagnosed with a mental illness; X For those with common chronic conditions, health care costs are as much as 75 percent higher for those with a mental illness as compared to those without a mental illness, and the addition of a co-occurring substance abuse disorder results in a two- to three-fold increase in health care costs; X Among dual eligible individuals (i.e., those beneficiaries covered by both Medicaid and Medicare), 44 percent have at least one mental health diagnosis;

12 Kathol, R. et al., Epidemiologic Trends and Costs of Fragmentation, Medical Clinics of North America 2006; 90(4): 549-72. 13 AHRQ, 2008, op cit. 14 For example, metabolic syndrome (e.g., obesity, elevated cholesterol, and high blood pressure) is associated with the intensive drug therapy used with these populations. 15 National Institute of Mental Health (NIMH), Distribution of Public Mental Health Expenditures by Public Payer (2003). Available online at: http://www.nimh.nih.gov/statitics/4DIS_PAYER2003.shtml. 16 AHRQ, Medical Expenditure Panel Survey, Statistical Brief No. 248, 2009. Available online at: http://www.meps. ahrq.gov/mepsweb/data_files/publications/st248/stat248.pdf. 17 Insel, T., Assessing the Economic Costs of Serious Mental Illness, American Journal of Psychiatry 2008; 165: 663-5. Although a huge sum, this does not include the costs of comorbid physical conditions, homelessness, incarceration, and early mortality. 18 Shirk, C., Medicaid and Mental Health Services, Background Paper No. 66, National Health Policy Forum, The George Washington University, October 23, 2008 19 NIMH, op cit. 20 Integrated Care Resource Center (ICRC), State Options for Integrating Physical and Behavioral Health Care, Technical Assistance Brief, October 2011.

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X For the 20 percent of dual eligibles with more than one mental health diagnosis, annual spending averages $38,000, which is twice as high as average annual spending for the dual eligible populations; X The prevalence of serious mental illness is especially high among dual eligible individuals under age 65, which is three times higher than dual eligibles who are age 65 plus; and, X Substance abuse disorder, with or without co-occurring mental illness, is also more common among dual eligible individuals than among Medicare-only beneficiaries. While behavioral health problems afflict all Americans, the cost and quality of care implications for Medicaid and dual eligible beneficiaries represent a marked challenge for the states and CMS. ESSEntIAl RolE of PRIMARY cARE The argument for connecting, coordinating, or otherwise integrating behavioral health with primary health care is to improve the treatment of the whole person, enhance clinical outcomes, and reduce utilization and costs. Because of the defining features of primary carecomprehensiveness, continuity, and coordinationit is designed to play an important bridging role in the care of people with chronic physical and behavioral health conditions.21 Quality of health and quality of life for patients with behavioral health problems, especially those with serious disorders, are not possible without primary care and mental health-related providers working in tandem. According to the Minnesota Evidence-Based Practice Center22 , there are eight main reasonssome already touched on earlierfor redesigning health systems and clinical practices to forge closer collaborations and connections between primary care and behavioral health: 1) People with mental health problems often do not receive treatment; 2) People with mental health problems are as likely to be seen in the general medicine sector than in the mental health sector; 23 3) Patients with less serious mental health problems are more likely to see a primary care physician (PCP) each year than a mental health specialist;24 4) Many people with mental health problems experience co-morbid physical health problems;25 5) Mental health problems can exacerbate disabilities associated with physical illness;26

21 Rothman, A. and Wagner, E., Chronic Illness Management: What is the Role of Primary Care, Annals of Internal Medicine, 138(3):256-61, 2003. 22 See AHRQ, 2008, op cit. 23 Rothman, A. and Wagner, E., op cit. 24 Wang, P. et al., Twelve-Month Use of Mental Health Services in the United States: Results From the National Comorbidity Survey Replication, Archives of General Psychiatry, 62(6):629-40, 2005. 25 National Center for Health Statistics (NCHS), Chartbook on Trends in the Health of Americans. Hyattsville, MD, 2007. 26 Kessler, R. et al., Comorbid Mental Disorders Account for the Role Impairment of Commonly Occurring Chronic Physical Disorders: Results From the National Comorbidity Survey, Journal of Occupational & Environmental Medicine, 45(12):1257-66.

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6) Evidence suggests that primary care physicians can effectively treat common mental health problems, such as depression and anxiety;27 7) Patients with SMI and SPMI often do not address their general medical needs, and are at higher medical risk than others without behavioral health disorders;28 and, 8) Certain drug therapies for mental health conditions can have deleterious effects on physical health. Given the above, integration can work in two directions to meet patients mental health needs: 1) specialty behavioral health services could be introduced into primary care settings; or, 2) primary health care could be introduced into specialty behavioral health settings.29 Nonetheless, it is important to recognize that the primary care setting may not be the best or most logical medical home for adults with chronic and unstable behavioral health problems which prove difficult to treat and manage; this population includes a significant number of individuals with SMI and SPMI. The rest of this paper focuses on person-centered organizational/service delivery and clinical options for integrating physical and behavioral health care for Medicaid beneficiaries and dual eligibles that fall into this narrowly-defined, but very challenging special needs group. IntEgRAtEd cARE oPtIonS foR MEdIcAId And dUAl ElIgIBlE BEnEfIcIARIES30 This section examines the options available to the states to integrate the organization, management and financing of behavioral and physical health services for Medicaid beneficiaries and dual eligible individuals with SMI and SPMI. 31 There are four (4) possible integrated care models: 1) managed care organizations (MCOs); 2) primary care case management programs (PCCMs); 3) behavioral health organizations (BHOs); and, 4) partnerships between MCOs/PPCMs and BHOs. While these models differ somewhat, they share the following characteristics: X Aligned financial incentives across the physical and behavioral health systems X Multidisciplinary care teams responsible for coordinating the entire range of physical health, behavioral health, and long term care services and supports on an as-needed basis X Use of a range of clinical integration tools32
27 Stein, M. et al., Quality of Care for Primary Care Patients with Anxiety Disorders, American Journal of Psychiatry, 161(12):2230-7; While PCPs are capable of identifying and treating depression and anxiety, they frequently fall below standard. 28 AHRQ, 2008, op cit. 29 Links between primary care and specialized addiction services have also been shown to be effective; see, for example, Druss, B. and von Essenwein, S., Improving General Medical Care for Persons with Mental and Addictive Disorders: Systematic Review, General Hospital Psychiatry, 28(2):145-53, 2006. 30 This discussion is based, in part, on the October 2011 technical assistance brief prepared by ICRC; see ICRC, op cit. 31 AHRQ, 2008, op cit. 32 Tools include comprehensive physical and behavioral health screening/assessment, joint care planning (beneficiary, caregivers, and providers), care coordination/case management, and navigation support.

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X Specialized provider networks X Real-time information-sharing with all members of the care team X Mechanisms for evaluating and rewarding quality care States will have to determine which of the above integrated care option(s) best suit their needs. States will have to determine which of the above integrated care option(s) best suit their needs. In making this decision, consideration should be given whether to: 1) leverage the existing Medicaid service delivery infrastructure or build new capacity; 2) make an MCO or BHO the lead integrating entity; 3) develop a single integrated care model, or specialized systems for subsets of the population; and, 4) implement different approaches in different regions of the state. These integrated care options are sketched below: Option #1Managed Care Organization (MCO) Medicaid MCOs have typically managed beneficiaries physical health care needs on a risk basis. Traditionally, MCOs have covered beneficiaries with limited behavioral health problems and/or states have carved out behavioral health care from MCO contracts. This option, on the other hand, creates a comprehensive managed care arrangement focusing on the totality of physical and behavioral health needs of enrollees; examples can be found in Minnesota, Tennessee, and Washington, Integration can be achieved through the integration of behavioral health benefits within the mainstream MCO33 or via contracting between mainstream MCOs and more specialized behavioral health MCOs.34 To accommodate dual eligibles, the integrated MCO should be a Medicare Special Needs Plan (SNP)35. Or at the very least, the state must obtain access to Medicare data for dual eligibles through CMSs Medicare-Medicaid Coordination Office.36 Option #1 more or less represents the most integrated, cost-efficient and accountable approach to bringing together and managing a broad package of physical and behavioral health services. It provides seamless access to needed benefits and goes a long way to achieving true clinical integration.37 However, strong oversight will be needed to ensure that enrollees receive the behavioral health care they need within the context of a mainstream MCO.38 Moreover, arrangements should be put in place to ensure that subcontracting, if employed, does not undermine the integrated nature of the model.

33 If subcontracting is permitted for behavioral health services, rigorous performance standards will be necessary to facilitate and support service access, coordination, and quality. 34 This arrangement is particularly well suited for Medicaid beneficiaries with SMI and SPMI. 35 For an overview of issues related to integrated care for dual eligible beneficiaries with special needs, see Kodner, D., September 2010, op cit.; A major drawback from the dual eligible point of view is that enrollment in SNPs is voluntary, thereby potentially affecting the financial viability of this approach. 36 For details on this initiative, see Centers for Medicare & Medicaid Services (CMS), Financial Models to Support State Efforts to Integrate Care for Medicare-Medicaid Enrollees, August 9, 2011. Available online at: https:// www.cms.gov/medicare-medicaid-coordination/08_FinancialModelstoSupportStatesEffortsinCareCoordination. asp#TopOfPage. 37 Issues related to clinical integration are addressed in the next section of the paper. 38 This is of particular concern, given the fact that individuals with chronic conditions are not always well served by MCOs and enrollees with special needs have also been known to experience problems with accessing specialized support services.

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John Iglehart in an introduction to a recent Health Affairs journal39 references the Lewin Group report that was prepared for the Americas Health Insurance Plans (AHIP), which concludes that studies strongly suggest that the Medicaid managed care model typically yields cost savings. However, Iglehart goes on to say that there are surprisingly few data available to indicate what he overall quality managed Medicaid will produce. He also quotes Diane Rowland of the Medicaid and CHIP Payment and Access Commission (MACPAC) who says we need to learn more about how these plans handle long-term care and chronic illness. Option #2Primary Care Case Management Program (PCCM) Under this option, the state could contract directly with providers or procure services through a PCCM contractor (operating either statewide or in one or more of its regions) in order to ensure the coordinated delivery of behavioral health services; versions of this model can be found in North Carolina and Vermont. The PCCM provides comprehensive primary care services to its enrollees on either a fee-for-service (FFS) or capitated basis40; in essence, it is the patients medical home.41 It would also connect them with needed behavioral health care, and maintains ongoing links with these specialized providers. Collaboration between primary and behavioral health care could be achieved through a variety of mechanisms and approaches, often in combination: 1) paying primary care physicians (PCPs) an enhanced fee to support care coordination/care management activities; 2) supporting the development of community-based care teams to reach out to patients and extend office-based practice42; 3) health information technology (IT) to support clinical information exchange, population health management, and performance measurement; 4) use of best practices in behavioral health screening and psychopharmacology; and, 5) formal linkages with the behavioral health system. Medicaid and Medicare funding streams are not blended. Thus, the flexibilities of a capitated model are not available. Nonetheless, if the PCCM is properly designed, it can move toward financial alignment between the two programs and also potentially provide the state with access to Medicare savings resulting from this integrated care option through the CMS Medicare-Medicare Coordination Office.43 Option #2 would be an excellent model for states to begin integrating physical and behavioral health services where PCCMs already provide the existing infrastructure of primary care. If capitation or other forms of global payment is not feasible, the option could still be implemented as a FFS program. PCCM also places the PCP in the frontline of behavioral health care, a much vaunted role. However, the flexibilities that come with the pooling of Medicaid and Medicare financing are not possible. And many challenges and much time are involved in developing ongoing relationships and collaborations with behavioral health providers.

39 Iglehart, J.Desperately Seeking Savings: States shift More Medicaid Enrollees to Managed Care, Health Affairs. September 2011, Vol. 30, No.9 40 Providers participate in both the Medicaid and Medicare programs. 41 PCCMs are beginning to organize themselves around the medical home model. Moreover, Medicaid-funded health homes, where they exist, are building close, complementary relationships with medical homes; the latter focus on the coordination of services and supports beyond the package of medical services. For a compact analysis of the medical home concept and its implications for special needs populations, see Kodner, D., October 2011, op cit; 42 The team could include behavioral health consultants, coordinators, counselors, and coaches. 43 See footnote 33.

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Option #3Behavioral Health Organization (BHO) Behavioral health organizations (BHOs) are well disposed to manage behavioral health services, especially those aimed at complex, high-need individuals in the SMI and SPMI cohort. In this option, the statethrough a partnership with the Medicaid agency, mental health agency, and county purchaserswould contract with one or more BHOs to manage a package of comprehensive behavioral and physical health benefits for a defined population, and the provider networks involved in delivering requisite services.44 Iowa is currently piloting this option; Arizona and Massachusetts are also pursuing the model.45 There are three (3) approaches that the model can take: 1) full-risk46 for behavioral health and physical health (Arizona); 2) full-risk for behavioral health and managed FFS for physical health (Massachusetts); and, 3) full-risk for behavioral health and FFS for physical health (Iowa). In order to serve dual eligibles, a population with a high concentration of individuals with chronic and serious behavioral health problems, the BHO would have to qualify as a Medicare SNP. An additional model is the one being pursued by the State of New Yorks Offices of Mental Health (OMH) and Alcoholism and Substance Abuse Services (OASAS) are jointly contracting with Behavioral Health Organizations (BHO) to monitor inpatient behavioral health services for fee-for-service Medicaid individuals and services for children with a serious emotional disturbance (SED) who receive care in OMH-licensed clinics. In New York, BHOs are entities with experience and demonstrated expertise managing behavioral health services for individuals with substance use and serious mental illness. In Phase 1 BHOs will monitor inpatient behavioral health services for Medicaid-enrolled individuals whose inpatient behavioral health services are not covered by (i.e., carved out of) a Medicaid Managed Care plan and who also are not enrolled in Medicare. In most cases, Phase I BHOs will begin operations in the fall of 2011 and will be fully implemented by January 2012. BHOs will be responsible for: X Concurrent review of behavioral health inpatient length of stay X Reducing behavioral health inpatient readmission rates X Improving rates of engagement in outpatient treatment post discharge X Gathering information on the clinical conditions of children with a Serious Emotional Disturbance who are covered by Medicaid Managed Care and receiving treatment in an OMH licensed specialty clinic X Profiling provider performance and testing performance metrics X Facilitating cross-systems linkage

44 These provider networks could include individual provider/provider agency contractors and MCOs. Depending on the state design, Medicaid-authorized health homes could also be connected to the BHO to implement care coordination/management and related services and supports; for a discussion of newly authorized Medicaid health homes, see Kodner, D., op cit. 45 This should not be confused with a New York initiative which contracts with BHOs to perform utilization management functions, rather than the coordination of care. 46 Full-risk for behavioral health services may or may not include the cost of related prescription medication. Nonetheless, BMOs would be expected to develop clinical pharmacy management capacity.

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Option #3 makes sense for Medicaid and dual eligible individuals with SMI and SPMI, especially where such organizations exist and already contract with the state. While there is very limited experience with the model, it can clearly serve as an important step to achieving full system integration between behavioral and physical health. While BHOs have managed care-like capabilities (e.g., care coordination/care management, information systems, and quality management), developing the capacity to also manage physical health services could be challenging47; qualifying as a Medicare SNP would be difficult, though not impossible. Finally, state oversight authority, including relationships between the Medicaid and mental health agencies, would have to be clarified. Option #4MCO/PCCM and BHO Partnership As pointed out in our earlier discussion of Option #1, states tend to limit the coverage of behavioral health services for Medicaid beneficiaries enrolled in MCOs or carve-out these benefits to a BHO; this also applies to PCCMs. Under this option, the state retains the separation between medical (physical health) and behavioral health care, but creates aligned financial incentives, including shared savings arrangements, or other performance-based approaches, to encourage closer coordination between the two systems.48 This model currently operates in Pennsylvania. To bring Medicare and Medicaid together, MCOs/ PCCMs operating in this model would have to share Medicare and Medicaid data with BHOs49, or the partners would have to access these data through the Medicare-Medicaid Coordination Office. In addition, states could pursue Medicare savings through CMSs recently launched financial alignment initiative. Option #4 enables states to pursue the integration of behavioral and physical health services without undertaking a major system overhaul. As such, this is the least powerful integrated care option available. Although Medicaid beneficiaries would gain better access to needed behavioral health care, the bifurcated system nonetheless stays in place; fragmentation at some level would likely remain an ongoing concern. Toward True Clinical Integration Financing, organizational and provider alignment in the models sketched above do not in and of themselves ensure clinical integration, that is, the coordination of patient level inter-professional teamwork, clinical decision support, and service delivery in a single process across time, setting, and discipline.50 Collins and associates, in their major Milbank Memorial Fund report on the integration of behavioral health in primary care, makes this abundantly clear.51

47 Especially if the BHO is not allowed to contract for physical health services and must, therefore, build this capacity internally. 48 Savings between MCO/PCCM providers, BHOs and the state can be shared on a capitated basis through reductions in per member per month (PMPM) costs or through back-end FFS calculations. Performance-based incentives are often associated with savings achieved from reductions in avoidable hospitalizations and emergency room visits. 49 While data-sharing is essential, the state will have to set clear privacy guidelines for the exchange of patientlevel information across both systems within the context of existing legal/regulatory constraints. 50 Kodner, D., Integration of Health Systems, Services and CareWhat Works and How?, Keynote presentation at the Inaugural Asian Conference on Integrated Care, Agency for Integrated Care, Singapore, February 25, 2011. 51 Collins, C. et al., Evolving Models of Behavioral Health Integration in Primary Care, Milbank Memorial Fund, 2010.

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In order to better understand what is actually needed to achieve true clinical integration for behavioral health patients, a brief review of the four quadrants of clinical integration would be helpful. This concept52, which is summarized in Table 1 on the next page, is used to match services, clinical approaches, and settings with the characteristics and needs of four (4) patient population types. This Four Quadrant Model is not diagnosis-specific; it considers the degree of clinical complexity, BH/PH risks involved, and level of functioning. When taken into consideration for each of the above population subsets, we can better understand the essential elements needed to achieve clinical integration:53 See below. Table 1: Four Quadrants of Clinical Integration Based on Patient Needs Quadrant II Quadrant IV BH PH
Patients with high behavioral health (BH) and low physical health (PH) needs (Example: Bipolar disorder and chronic pain) Served in BH setting or primary care (when mental health needs are stable)

BH PH
Patients with high behavioral health (BH) and high physical health (PH) needs (Example: Schizophrenia and metabolic disorder or hepatitis C) Served in BH setting or primary care (when mental health needs are stable)

Quadrant I BH PH
Patients with low behavioral health (BH) and low physical health (PH) needs (Example: Moderate alcohol abuse and fibromyalgia) Served in primary care setting

Quadrant III BH PH
Patients with low behavioral health (BH) and high physical health (PH) needs (Example: Moderate depression and uncontrolled diabetes) Served in primary care setting

52 See Mauer, B., Behavioral Health/Primary Care Integration: The Four Quadrant Model and Evidence-Based Practices. 53 See Parks, J., Bartels, S., and Mauer, B., Integrating Behavioral Health and Primary Care Services: Opportunities and Challenges for State Mental Health Authorities, National Association of State Mental Health Directors, January 2005.

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X Quadrant I Primary care-based BH Primary care physician (PCP) with standardized screening tools/BH practice guidelines X Quadrant II54 BH case manager with responsibility for coordination with PCP PCP with standardized screening tools/BH practice guidelines Specialty BH Residential BH Crisis/ER BH/inpatient (IP) Other community supports X Quadrant III PCP with standardized screening tools/BH practice guidelines Care/disease manager Specialty medical/surgical ER Medical/surgical/IP SNF/home-based care Other community supports X Quadrant IV55 PCP with standardized screening tools/BH practice guidelines BH case manager with responsibility for coordinating with PCP and Care/disease manager Care/disease manager Specialty medical/surgical Specialty BH Residential BH Crisis/ER BH and medical/surgical/IP Other community supports In summary, the Four Quadrant Model is not meant to be prescriptive. It is a template designed to assist in local BH system planning. Therefore, it should be very useful to integrated care entities and their partners in the design and development of clinical systems and strategies. Summary Behavioral health is a major health care concern. Despite improvements over the past fifty years in terms of how me treat and manage mental health and substance abuse disorders, the system still faces considerable challenges. The fragmentation of care at the system and clinical levels remains an important barrier to quality, cost-effective behavioral health care.
54 55 Includes patients with SMI and SPMI. Ibid.

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Since mental and physical health problems are interwoven, comprehensive, integrated solutions are demanded. This idea is supported by public payers, especially Medicaid, which pays the lions share of costs, as well as advocates and providers alike. Integrated care models, which are designed to link and coordinate the behavioral health system with primary care settings and providers, are being increasingly pursued by the states and CMS to address the needs of Medicaid and dual eligible beneficiaries. For the most part, the emphasis is being placed on the serious, complex and costly needs of individuals with and SPMI; these individuals would benefit the most from integrated care. In this paper, we have explored the rationale for bringing behavioral and physical health services together, as well as the critical role that primary care plays in bridging these two systems in order deliver quality, effective, holistic care to people with mental health and substance abuse disorders. We also examined four more or less integrated models of behavioral and physical health care for the adult Medicaid population. Also touched on was how these options could be retrofitted to serve dual eligible individuals. In making their decision about which option(s) to follow, the states will have to consider how such models fit with the existing infrastructure of Medicaid-funded behavioral health and primary care services. Other important considerations include whether to develop specialized behavioral health plans and whether BHOs should be made the lead integrating entity. Finally, even the most organizationally and financially integrated model sketched here does not guarantee the delivery of clinically integrated care. In forging clinical systems and strategies to meet the needs of patients with a combination of behavioral and physical health needs, the lead integrating agency and its partners must first carefully examine the clinical complexity, BH/PH risks, and level of functioning for each of the patient subgroups in the target population. Only then can they define the services, methods and tools needed to achieve clinical integration. The Four Quadrant Model described in this paper offers an important planning framework in this regard. One last point bears mentioning: State legislators, advocates and citizens will need to be convinced that integrated care solutions for behavioral health care is a good thing, particularly managed care models that combine the two systems under one roof. Since mental health and substance abuse services are largely funded with state dollars, the states must use their authority to establish clear clinical guidelines, quality standards and outcome measures for integrated care programs; they must also put in place strong oversight. Only then can the transformation of behavioral health into a highquality, cost-effective system move forward under the banner of integrated care.

*This paper was authored by Dr. Dennis L. Kodner and prepared with the support of the Author Webb Group, Inc. Dennis Kodner, PhD, FGSA is a global thought leader on health systems/services integration. He is an expert on coordinated care and managed care systems for people with chronic, disabling, medically complex, and high-risk conditions, including the frail elderly and those whose needs cut across the health, long term care, mental health, and social service systems. Arthur Y. Webb Mr. Webb has extensive experience in the policy and practice areas of serving high needs, high cost individuals. See www.arthurwebbgroup.com