December 2019, Volume XXXIII, No 9
Serving behavioral health patients
Jennifer J. Garber, LICSW
Your new position recognizes, from a payer’s perspective, the role of behavioral health in lowering the cost of care and improving outcomes. What can you tell us about this vision?
UCare recognized that we wanted to better support members with behavioral health challenges. We set up a team to work with members, families, providers, and other key constituents to assist with assessing members’ situations and their timely access to quality services. We established a toll-free number for members, families, and providers to get assistance, and built more robust case management support. People with medical concerns, particularly chronic medical conditions, may also have behavioral health challenges, and have been shown to have significantly higher overall claims costs. We are focused, not just on intervening with members with behavioral health concerns, but also active and chronic medical concerns as well, knowing this will support member’s overall health and quality of life, and positively impact claims costs.
How can integration of behavioral health teams with other elements of health care delivery improve patient outcomes?
Here’s one example that UCare has supported. Hennepin Healthcare’s Emergency Department proposed a project to hire Licensed Alcohol and Drug Counselors (LADCs) to consult with ED staff and immediately engage with patients. Historically the focus of the ED was to medically stabilize the patient prior to sending them on their way. Having the LADC staff available allows them to stabilize the patient medically while also immediately addressing their substance use disorder. This may mean starting patients on a regimen for Medication Assisted Therapy in the ED and referring them to the onsite clinic for followup, or referring them for other treatment services. M Health Fairview is another example; they now place behavioral health professionals in the primary care setting. When the primary care provider identifies a behavioral health concern, they can immediately connect the patient with the behavioral health resource, who can assess the situation, and even see the patient for a limited number of sessions or make referrals to other behavioral health providers.
Behavioral health equity focuses on the importance of all people having access to services.
What is behavioral health equity and why is it important?
The Substance Abuse and Mental Health Services Administration (SAMHSA) defines behavioral health equity as “the right to access quality health care for all populations regardless of the individual’s race, ethnicity, gender, socioeconomic status, sexual orientation, geographical location and social conditions through prevention and treatment of mental health and substance use conditions and disorders. Behavioral health equity builds on a general definition of health equity and directs specific attention to mental health and substance use conditions and disorders.”
Behavioral health equity focuses on the importance of all people having access to services that are going to contribute to their overall good health, regardless of any specific demographic qualifiers, and supports the overall sense of the importance of behavioral health parity. A person should have access to behavioral health services in kind with the medical services and benefits that are available to them.
Adverse Childhood Experiences (ACEs) are now widely recognized as a health care concern. What can you tell us about ACEs?
“ACEs” include all types of abuse, neglect, and other potentially traumatic experiences that occur to people under the age of 18. These experiences have been linked to risky health behaviors, chronic health conditions, low life potential, and early death.
The Centers for Disease Control and Prevention (CDC), in conjunction with Kaiser Permanente, surveyed 17,000 people regarding their childhood experiences and current health status and behaviors. This study demonstrated that the total sum of the different categories of ACEs corresponds to negative health and well-being. Some populations are more vulnerable to experiencing ACEs because of the socio-economic conditions in which they live, work, and play. Outcomes associated with ACEs include mental health concerns (such as depression, anxiety, suicide, and PTSD); unintended pregnancy and complications; HIV and other STDs; cancer; diabetes; alcohol and drug abuse, unsafe sex; and reduced overall success in education, occupation, and income.
Please tell us about your products for special needs populations.
These products are for adults between the ages of 18–64 with certified disabilities. There are two types of plans: those that combine Medicare and Medicaid benefits, and those that only have Medicaid benefits. By nature, these members have complicated health concerns (medical, developmental, behavioral), and likely will need extra support. The plans provide members with a care coordinator who helps ensure that the needed services are in place and are coordinated. These plans also have unique benefits, such as a health club membership.
What can you tell us about your new behavioral health hotline?
Our new behavioral health-dedicated line provides members, families, concerned persons, and providers a direct pathway to the behavioral health-specific team, who have had specialized training and experience with regards to behavioral health concerns, challenges, and resources. We expect that we will have the opportunity to help connect people with the best possible resources for their specific situation, both utilizing their health plan benefits and things that fall outside their benefit set; help them be educated about how and what to expect; help triage their specific situation; and expediently and appropriately get them connected with resources. We know there are times when members will call us in the midst of their personal crisis. We have no higher priority than taking that call at that point.
Please comment on the emerging field of comprehensive medication management.
UCare covers comprehensive medication management services for all of our lines of business (Medicare, Medicaid, and Health Exchange). Additionally, UCare currently has a formal medication management protocol in place for some products, and is looking for ways to expand this program in the future. This protocol is for patients who have a certain constellation of complex medical conditions, and/or are on multiple medications. The program includes an appointment with a pharmacist to do a comprehensive review of all medications at least annually, and outreach calls on a quarterly basis, if there are any newly identified concerns. If there are gaps identified in the treatment regimen, this may also result in an outreach call to the member and/or their physician. It is designed to support both the patient and their physician in the most effective combination of pharmaceuticals for our members’ optimal health.
What can you tell us about your expanded behavioral health case management and how it improves treatment delivery?
UCare has historically offered case management services for members who have behavioral health challenges, as well as medical conditions. We are significantly increasing the availability of those resources to assist those with either short-term or long-term needs. This will include providing these services to members who have behavioral health challenges only, but also for those who have both medical and behavioral health challenges. This is being rolled out product line by product line, and will include coordination and collaboration with other key providers and partners, working with the individual using a member-centric model focused on recovery and resiliency for the member.
It is critical that the member be involved in this process, and that we support them in what actions/supports need to be put into place in order to accomplish their goals, and have overall quality of life and improved health. We are also exploring partnerships with provider agencies to provide “feet on the street” care management for specific situations.
What should physicians know about recently enacted and proposed legislation around behavioral health?
It would be beneficial for physicians to know about three key legislative priorities:
Behavioral Health Parity (BH Parity) is legislation designed to ensure there is equity with a patient’s insurance policy so that the benefit structure, limits, and processes are no more restrictive on the behavioral health services than they are on the medical side. It does not ensure that a patient’s policy includes behavioral health benefits. There was a recent legislative change to require BH Parity in the areas of Non-Quantitative Treatment Limitations, which include, for example: medical management standards limiting or excluding benefits based on (i) medical necessity or medical appropriateness, or (ii) whether the treatment is experimental or investigative; formulary design for prescription drugs; fail-first or step therapy protocols; and limitations on inpatient services for situations where the enrollee is a threat to self or others.
Substance Use Disorder (SUD) Reform is a package of changes designed to move the treatment services for SUD from an episodic model to a set of services more effectively designed to provide ongoing care using a chronic care model, similar to how diabetes is treated. A number of changes were made to the SUD service continuum, including treatment coordination and Peer Support services, as well as withdrawal management. Another key change is that the system will allow direct access, which should enable patients to get into treatment with fewer hurdles.
Workforce: Psychiatry, psychology, clinical social work, psychiatric nursing, marriage and family therapy, and professional clinical counseling are considered the “core” mental health professions. Licensed Alcohol and Drug Counselors and Peer Support/Certified Peer Specialists have recently been added to that cadre. For many years, Minnesota has experienced a shortage of providers of behavioral health services. This shortage has been felt most profoundly in rural areas of the state. There is also an ongoing shortage of culturally competent and culturally specific providers.
For physicians, this means that people have fewer specialists available to them, so the place that they will often go to get support will be the primary care setting. It is important to work together to support primary care, to not overwhelm this resource, and to provide needed support to members.
What goals do you have for the future of UCare’s behavioral health services?
My goal is for UCare to firmly be established as the leading health plan that provides excellent behavioral health support for members and the community. I foresee a model that includes: direct access for members and family members; ongoing support for members and family members who may need short-term or long-term services; key collaborations with partners, such as providers, counties, regulators, and advocacy groups; and innovations to help fill the gaps for all members and family members. This would also include successful integrated care models, impacting the overall quality of life for members, including supporting them in areas such as social determinants of health. And ultimately this will fit hand in glove with managing overall claims costs while members receive effective and efficient health care.
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