Highlight on Massachusetts: Rethinking coordination and care for mental health

The state of Massachusetts could be doing more to coordinate care, acquire data, raise quality, and lower costs for individuals with behavioral health needs, according to a  health care cost trends report from Massachusetts Attorney General Maura Healey. The report indicates that due to a lack of coordination between insurers and health care providers, patient access to behavioral care and information about payment levels for that care are compromised.

Mental Health Needs

Mental health needs are significant in Massachusetts and across the country, with 19 percent of adults suffering from a mental health condition between 2012 and 2013. On top of those numbers, the report cited data suggesting that the prevalence of mental health issues is growing. The report was designed to examine approaches to management of behavioral health benefits and payment for behavioral health services by commercial and government payers.

Fragmentation

The report focused on the fact that while health plans generally pay providers directly for delivering non-behavioral health care services, most Massachusetts health plans “carve out” behavioral health and subcontract the management and administration of behavioral health benefits to specialized companies called managed behavioral health organizations (MBHOs).  As a result, consumers covered by these plans have to deal with separate entities for behavioral health and medical benefits. According to the report, the division of responsibility created by the separate systems makes it difficult to determine what is being spent on behavioral care, is a disincentive to coordination between mental health and medical care providers, and makes it harder for patients to access the care they need.

Administration

The parallel system complicates patient experiences. In circumstances where patients suffer from a chronic medical condition, care coordination is already complex. The report uses a hypothetical example of a patient with  high blood pressure and low back pain who is hospitalized for evaluation of a possible heart attack. Throughout the patient’s care experience, the patient meets with multiple different providers—specialist, chiropractor, emergency department, primary care provider. The report explains that care in such a scenario is complex and requires challenging care coordination between the various providers. However, the report explains that when the same patient, with the same symptoms, is also burdened by a behavioral health or substance abuse problem, the patient’s care becomes considerably more complex. In the hypothetical example, the addition of an opioid abuse problem could add several providers to the list of those involved, including: an addiction counselor, an inpatient substance abuse unit, and an outpatient addiction program.

Financial Incentives

In addition to the administrative hurdles, the report indicates that medical and behavioral health service providers are not financially incentivized to coordinate care. Because many global budget health plans simply exclude behavioral care from the global budget and place the responsibility for the behavioral costs on MBHOs, the report indicates that MBHOs are not encouraged to engage in integration efforts across the behavioral and medical health barrier. The report recommends that global health budgets be modified to account for the “indivisible nature of patients’ medical and behavioral health needs.”

Reimbursement Rates

The report also addresses the problem of historically low behavioral health reimbursement rates. It suggests that one reason for the low reimbursement levels is the prevalence of financial arrangements that transfer of some or all of the risk of behavioral service costs onto MBHOs. Additionally, the report cautions that consistent losses on behavioral health business discourage investment in behavioral health care, which impacts consumer access to these important services.

Data

The report acknowledges that reporting on behavioral health utilization, price, spending, and quality varies significantly among behavioral health providers. However, reporting on utilization, price, spending, and quality of behavioral care lags behind reporting of the same information for medical care. Massachusetts should give the same importance to data collection and reporting for behavioral health services as it gives to medical services. Without such data, the state cannot meaningfully invest in behavioral health care or understand spending trends.