10 Integration Models Reshaping Behavioral Health Delivery

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Introduction

In the 1980s and early 1990s, health services researchers began documenting that many of the individuals who saw primary care physicians were identified as having serious mental illnesses (SMI). These individuals with SMI were more likely to have a higher number of medically unexplained symptoms, more comorbid illnesses, and more functional impairments like diabetes and heart disease. These individuals also typically used twice as many health care services as their counterparts, costing insurers twice as much in resources.¹

Studies during this time showed only a quarter to half of patients with SMI were accurately diagnosed by primary care physicians. Even if the individuals were accurately diagnosed, most of those patients did not receive the proper amount of prescribed psychotherapy or pharmacotherapy from their primary care doctors, causing many suffering individuals to discontinue therapies within the first few weeks, and never complete a referral to see a mental health provider.

These gaps in care between primary care and behavioral health are often more pronounced among minority populations and individuals living in poverty, two key demographics that already lack access to quality mental health services. Today, many behavioral health providers and primary care physician practices are working together to provide more integrated solutions for individuals that combine mental health and primary care services, rather than keep them separate as has typically been the norm in the United States.²

Understanding Integration

“Integration” is changing the competitive advantage for health and human service provider organizations—and with it, changing the parameters of financial sustainability. Integration brings with it value-based reimbursement (VBR), consolidation, and leverage of technology. Providers are finding new ways to provide old services and the COVID-19 pandemic has undoubtedly hurried some of these new technologies along to reach individuals whose mental health has been affected by the pandemic and its economic fallout.

However, there is no specific definition or a single type of integration. Integrated care models vary in how information is shared, how services are delivered, and the financial incentives among the stakeholders. Additionally, in all integration models, the issue of data exchange becomes top-of-mind and presents challenges as the market moves toward sharing data to increase care effectiveness. For this reason, integration models often vary significantly from one market to the next.⁶

The types of integration models affect service lines, revenue, margins, and sustainability for providers and the patients they serve. Here are the top 10 models of integration that are emerging in the U.S. health and human services field.

Model 1: Virtual Specialty Care Embedded In Health Plans

Definition: A health plan contracts with an organization or smartphone application that provides health care services in a “completely
virtual” delivery system. Examples of this include the many wellness teletherapy and e-counseling services advertised widely, such as TalkSpace, MDLive, and Doctor On Demand.

Market Implications: These virtual delivery systems, such as virtual behavioral health provider networks, directly contract with individual health care providers and health plans, thus giving them an advantage in direct referrals and access for consumers. This raises the bar on performance as well as convenience and cost.

Model 2: Virtual Specialty Health Plans

Definition: A full-service health plan designed for a specific group of consumers with shared characteristics. An example of this is PASSE – Provider-Led Shared Savings Entity, a program that serves Arkansas’ Medicaid clients with complex behavioral health, developmental, or intellectually disabilities. The Arkansas PASSE was legislatively mandated in 2017 through the passing of Act 775. Each of the five PASSE organizations have a majority ownership by provider organizations which perform the administrative functions similar to insurance companies such as claims processing, member enrollment, and grievances and appeals. Each of the PASSEs must be compromised of an IDD provider, a BH provider, a hospital, a physician, and a pharmacist which assume financial risk for total cost of care for which they receive a capitation payment that includes shared savings (and losses). PASSEs are a new Medicaid provider type under Section 1915(b) authority This program aims to better coordinate care for this specific population. The hope is that this coordination of care will keep individuals healthier, and, as a side benefit, also keep costs under control.

Only Arizona, Iowa, Kansas, Maine, and Vermont like Arkansas have shifted accountability for the physical health, behavioral health, and long-term services and supports for their IDD populations.

Market Implications: Vertical specialty health plans can cover all health care services (not just specialty services) and typically require contracting with a managed care entity and formal collaboration with other health care organizations.

Model 3: Primary Care Services With Tech-Enabled Specialty Care

Definition: A primary care practice or community health center that offers specialty care through on-site virtual platforms. With this model, a primary care provider provides mental health services to patients usually via web camera offered on-site at the primary care provider’s office.

Market Implications: Specialty care delivered on a virtual platform allows for broad geographic competition for local specialty care provider organizations. With the shortage of behavioral health specialists, this virtual approach will allow areas without many mental health providers to tap into resources in other areas.

Model 4: Virtual Hospitals At Home & Telehospital Medicine

Definition: Acute care services provided at home with some on site and some virtual medical professionals. In November 2020, CMS implemented a waiver for its new Acute Hospital-At-Home program. The program provided regulatory flexibilities allowing eligible hospitals to treat consumers in their homes through the duration of the COVID-19 Public Health Emergency. For fee-for-service Medicare beneficiaries eligible for the Acute Care Hospital-At-Home program, the sponsoring hospital will provide symptom and vital sign monitoring twice daily, and any ancillary services normally provided for the person’s condition. All billing and coding requirements remain the same as those for inpatients treated at other alternative care locations operated by the hospital during the public health emergency.

Medicare inpatient payment policies and rates have not changed because of this waiver. Medicare inpatient payments to a hospital will be the same as they would have been if the care were provided in a traditional inpatient setting.³

Market Implications: CMS believes that with proper monitoring and treatment protocols, treatment for more than 60 non-COVID-19, acute conditions (including asthma, congestive heart failure, pneumonia, and chronic obstructive pulmonary disease) can be treated appropriately and safely at the individual’s home rather than being physically in the hospital.

So far, the waiver is only for those consumers and only during the pandemic public health emergency. However, outcomes research obtained during this waiver period will likely determine if the program continues post-pandemic.

Model 5: Children’s Coordinated Care & The Pending CMS Children’s Health Home Proposal

Definition: A specialty care coordination program for children with complex medical, behavioral, or social conditions, such as cerebral palsy; cystic fibrosis; HIV/AIDS; blood diseases like anemia or sickle-cell disease; spina bifida; epilepsy; severe autism spectrum disorder; and serious mental illnesses.

Market Implications: Like medical homes for adults, these organizations aim to coordinate prompt care for children with complex conditions, which presents both a market opportunity and
threat to traditional referral channels. CMS had initially planned for these awards to start in October 2022; however, COVID-19 has altered many timelines.⁴

Model 6: Health Plan/Health System Provision Of Long-Term Care Services

Definition: Long-term care for people with complex and chronic conditions, included in performance-based and value-based reimbursement initiatives.

Market Implications: Organizations that want to deliver long-term care must be prepared to contract with larger organizations—and to create a collaborative care network, implement decision
support, measure consumer experience, monitor financial performance, and master data collection and reporting.

Model 7: Expansion Of The Retail Health Concept

Definition: Medical clinics physically located inside pharmacies, grocery stores, and other large retail stores with weekend and evening hours, short wait times, telehealth services, and online registration, such as CVS, Walgreens, and Wal-Mart.

Some of these clinics take insurance and some require cash payment up front, but fees are generally posted ahead of time and aim to be affordable, even for the under- and uninsured.

Market Implications: The retail model provides direct competition for face-to-face specialty service delivery at a low unit rate.

Retailers usually have a local footprint in the community already and this gives consumers a reason to visit their space.

Model 8: Health Plan-Sponsored, Tech-Enabled, In-Home Primary Care

Definition: Consumers can access their primary care provider—and some specialty care services—
in their homes via smartphone or web platform. Many consumers and providers had a taste of this during the early days of the pandemic and are energized by the possibilities.

Market Implications: Service delivery for specialty services is often facilitated through primary care service delivery platforms—and these systems will control specialist referrals.

Model 9: Health Plan/ACO/Health System Risk Alignment

Definition: Health plans contract directly with accountable care organizations for all health services using value-based reimbursement (VBR) contracting models that share financial risk.

Market Implications: Because accountable care organizations (ACOs) are largely owned and operated by health systems and other provider organizations, referrals to independent specialist provider organizations are reduced in these arrangements.

Model 10: Fully Integrated Health Plan/Health System Models

Definition: With a fully integrated health plan, a single organization is both the fiscal insuring organization and the clinical service delivery organization. An example of this is the Philadelphia Integrated Care Network that integrates primary care and behavioral health as a way to reduce costs, wait times, and stigma, with an emphasis on reaching low-income and minority groups.

Market Implications: These hybrid organizations have their own service delivery network and the volume of referrals to specialty provider organizations is reduced.

About The Guide

The Third Edition of Trends in Behavioral Health provides information and insights into the multilayered United States behavioral health system. The guide includes an in-depth view of current statistics, prevailing issues, and emerging trends in order to inform the discussions, debates, and decision-making of policy-makers, payers, providers, advocates, and consumers. The guide is especially relevant today as it explores many of the health care changes that have occurred during the COVID-19 pandemic and how they will impact care going forward.

About PsychU

The PsychU community is comprised of more than 61,000 physicians, psychiatrists, nurse practitioners, physicians assistants, clinicians, care managers, nurses, pharmacists, medical directors, payers, administrators, and other mental health care professionals dedicated to improving the future of mental health care through information, discussion, and collaboration. Membership is free and provides complete access to all programs and resources on PsychU. PsychU is supported by Otsuka Pharmaceutical Development & Commercialization, Inc. (OPDC), Otsuka America Pharmaceutical, Inc. (OAPI), and Lundbeck, LLC., and is managed by OPEN MINDS – committed supporters of the mental health treatment community. Editorial development and support for PsychU is provided by OPDC, Oxford Pharmagenesis, Inc., MedThink SciCom, a division of MedThink Inc., and it OPEN MINDS, who have been compensated for their services. Learn more about the community, or become a member today by visiting www.PsychU.org.

Sources

1. Intentional Approaches to Integrated Care: Results of a 2020 National Survey of Behavioral Health and Intellectual and Development Disability Providers with Case Studies. (2021, February 10). Retrieved October 6, 2021, from https://integratedcareonline.com/intentional-approaches-to-integrated-care/
2. Oss, M. (2021, September 28) Making Integration Work – Think Change Management. Retrieved October 6, 2021, from https://openminds.com/market-intelligence/executive-briefings/making-integration-work-thinkchange- management/
3. CMS Launches New Acute Care Hospital-At-Home Waiver Program. (2021, February 15). Retrieved October 6, 2021, from https://openminds.com/market-intelligence/news/cms-launches-new-acute-care-hospital-athome- waiver-program/
4. CMS To Launch Health Homes For Children With Medically Complex Conditions. (2019, May 12). Retrieved October 6, 2021, from https://openminds.com/market-intelligence/news/via-medicaid-servicesinvestment-accountability-act-cms-to-launch-health-homes-for-children-with-medically-complex-conditions
5. Behavioral Health Delivery System, OPEN MINDS Proprietary Database
6. Oss, M. (2020, April 30). Ten integration MODELS Reshaping specialty service delivery. Retrieved October 6, 2021, from https://openminds.com/market-intelligence/editorials/ten-integration-models-reshapingspecialty-service-delivery
7. Change Management Lessons to Prepare Your Organization for Integrated Care. (2021, June 25). Retrieved October 06, 2021, from https://integratedcareonline.com/change-management-lessons-to-prepare-yourorganization-for-integrated-care/

For additional insights and information, download the full guide, TRENDS IN BEHAVIORAL HEALTH A REFERENCE GUIDE, on the US Behavioral Health Financing & Delivery System, at www.psychu.org/guide-third-edition. Or, contact your Otsuka account executive to setup a meeting.

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