Interest in Integrated Behavioral Health and Primary Care Increasing

Posted on November 25, 1997

Recent conferences such as the third national Primary Care/Behavioral Healthcare Summit and the Medicaid Working Group's Managed Care and Disability: Consumer Needs and Quality Measures explored ways that primary care health plans can include behavioral health care services.

The Medicaid Working Group focuses on integrated health care designed for Medicaid recipients with serious disabilities. This consulting group had its origins in-and continues to be closely involved with--an unusual Boston-based health maintenance organization--an HMO solely for people with disabilities called the Community Medical Alliance (CMA). The Medicaid Working Group uses this practical hands-on experience to assist state government efforts to extend managed care from the AFDC (Aid to Families with Dependent Children) population to Medicaid beneficiaries with disabilities. Given that Medicaid enrollees with disabilities make up approximately 16% of Medicaid recipients while using roughly 40% of Medicaid funding, state governments seek ways to enroll people with disabilities in managed care as a cost-control measure.

The Medicaid Working Group's experience began with people with severe physical disabilities and people with HIV/AIDS and now--in an integrated primary care/behavioral health care model--includes enrollees with a primary diagnosis of a serious mental illness. As states consider enrolling SSI recipients with disabilities in managed care, either with behavioral health carved-out or carved-in (overseen by the same entity managing primary care), the learnings from the Medicaid Working Group's public sector consultations are relevant. They include:

1. Ignorance, hostility and skepticism abound about requiring people with disabilities to join managed care plans.
2. Existing managed care models, designed for people in good health, lack the experience and expertise to treat people who are chronically ill and often severely disabled.
3. The debate continues about whether it is better to include people with disabilities in mainstream managed care plans or provide enrollment in specialized managed care plans--like the Community Medical Alliance-- or have specialty sections for people with disabilities within a larger managed health care plan.
4. The need to increase rates for people with disabilities is critical if managed care is to be satisfactory for people with disabilities. Interest in research on rate-adjustment and health-based payment systems is increasing. The use of "one rate fits all or even one rate fits all people with disabilities" just does not work. Risk-adjustment is necessary to ensure that managed care plans develop adequate models of care for people with disabilities.
5. Managed care plans must abandon pure "medical model" service delivery for a broader view encompassing social services and linkages with housing, rehabilitation, and community supports.
6. Consumers are key stakeholders who have been underutilized in the design of managed care plans.
7. Competent, specialized providers who have traditionally been the caregivers for people with disabilities need to be incorporated into the new managed care programs.

These findings apply to people with severe mental illnesses as well as to people with other disabilities.