A survey of state-based behavioral health integration with Beacon Health Options

Across the country, states are working in various ways to integrate behavioral health into more traditional medical approaches to caring for physical health.  This is happening both at the financial and clinical levels.

However, while mainstream opinion has embraced the idea of behavioral health integration, the manner in which that strategy gets implemented varies widely across and within states.

Beacon Health Options is one of the largest managed behavioral health care organizations in the country.  Their in-state footprint ranges from large (running the statewide mental health system in Massachusetts) to small (operating the crisis system in a few counties in Washington State).  The organization’s work varies from the Dept. of Defense to commercial carriers, and publicly funded health plans, as well as a range of medical and behavioral health providers in both urban and rural settings.

So, I wanted to get Beacon’s organizational perspective on behavioral health integration, and allow some of its leaders to survey some of the highlights of various state-level work that excites them.

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I spoke with three Beacon executives recently:  Eric Van Allen, Chief Partnership Officer for the Western US; Mark Heit, Chief Partnership Officer for the Midwest; and Sarah Arnquist, Vice President of Client Partnerships.

We talked through Beacon’s work in Colorado, Washington State, and Arkansas, and looked ahead to some of the work they hope to be doing in Alaska.


 

DJ:  Traditionally in Medicaid, states that are thinking about mental health care coordination are often also managed care states or have some sort of MCO footprint on the medical side of health care.  How does the role of the MCO fit into behavioral health integration?

Sarah Arnquist: “In the regions where we work with MCOs, they actually look to us to be the leaders and convener in the behavioral health space.  MCOs appreciate that we take the lead and organize and convene and drive the behavioral health agenda.  Behind the scenes, we all work together to set an agenda for integration, but out in front, MCOs look to Beacon to elevate a series of topics.

There are so many stakeholders involved that you need a strong focus on behavioral health to make sure that perspective remains elevated as integration moves forward.  Integration is important, but there are people that will need a specialty system of care.  MCOs focused on numerous medical issues, not singularly focused on behavioral health like we are.

DJ:  Give me an example of how that plays out in practice.

SA:  The behavioral health crisis system is where the gaps show up.  It’s the canary in the coal mine.  It’s where people will fall through the safety net if you don’t have an organization directly thinking about the behavioral needs of the individual and the community in a time of crisis.

That’s not a space where MCOs or even states have a lot of expertise.  And county-led models don’t usually understand the medical side of the integration equation.  So, there has to be a coordinator on the BH side to make sure that the safety net holds together during an acute behavioral health event.  MCOs are playing that role on the physical health side, so we become partners as integration moves forward.  That leadership and orchestration behind the scenes is critical. In any system of care, there has to be this leadership and collaboration, regardless of which MCO it is.

DJ:  So, give me an example of where Beacon has developed or participated in an approach to behavioral health integration that was unique, that leveraged your national expertise, but which was localized for the community.

Mark Heit:  In Colorado, we’ve merged what was a “care coordination program,” with a traditional behavioral health carve out, into single regional entities that manage and integrate both physical and behavioral health.  Beacon operates two entities in the market under that regional accountable entity structure, or what are called “RAEs.”  Those entities are responsible for a range of outcomes, including behavioral health, the social determinants and traditional physical health.

That’s a model where we built something entirely unique in Colorado, because that was what the local community wanted and what worked for them.

Beacon’s approach there has been to build a very close partnership with a group of providers, including FQHCs and CMHCs.  We operate under a co-governed model that is truly focused on a collectively defined strategy between Beacon and providers that is intended to serve our members.  This isn’t managed care over the top.  This is a bottom up collaboration with community providers to meet member needs at the local level.

DJ:  Is that a common approach, to be close partners with providers in this process?  I mean it sounds great, of course, but it doesn’t always work that way in health care, does it?

Eric Van Allen:  We are unique in the market that we partner with providers in a meaningful way.  I think providers feel different about working with us compared to MCOs or other organizations because we are so focused on collaboration.

The majority of the spending in any given BH system goes to a narrow group of beneficiaries with a very challenging set of issues.  So, it takes a lot of eyes, a lot of different organizations, specialities and care givers to really positively impact some of these more challenging issues or episodes.  So, to be successful, it takes a real willingness to work closely with providers, to partner closely with providers, that I think – candidly – makes us pretty unique in the market.

MH:  Now, just to be clear, a joint venture like what we’re doing in Colorado or in Arkansas, isn’t the right pathway for every community.  It takes a lot of trust, engagement, and a very strong sense of values alignment.  That said, a lot can be accomplished through creative contracting.  But the point is that the interest in collaboration matters tremendously.

DJ:  Tell me about the approach in Arkansas.

MH: In Arkansas, the big difference is that the program being built is exclusively built on a provider partnership model.  The “Provider-Led Shared Savings Entity or PASSE” program is a fully integrated program across an array of services, including medical, pharmacy, behavioral health, and long term care.

The model in Arkansas has to be at least 51% provider owned.  So, the governance model needs to be sure to include the voice of a PCP, hospital, pharmacist, a home and community based service provider for IDD services, outpatient mental health, inpatient.  The model there is fully capitated, and includes seriously mentally ill (SMI), and the child corollary for serious emotional disturbance.  It includes adults and kids with intellectual developmental disabilities.  Again, this is full risk, fully capitated for all benefits, where the entity is responsible for care coordination in the program.

Beacon is the administrative contractor to the parent entity, which is called “Empower.”  That means we are an owner and an administrative partner with about 400 staff operating on the ground in Arkansas.

The approach was born out of an acknowledgement that the community needs to guide what is necessary to improve the outcomes for the community.

DJ:  Alaska is a unique state with unique geographic, demographic and financial considerations.  I know you’re hoping to do work in Alaska.  How does this national perspective inform the work you want to be doing in a state like Alaska?

EVA:  Our vision is informed by the collaborative nature of how we do business in other states.  So, how we build an Alaska model of care that is unique and applicable to the Alaska’s challenges starts with conversations with our provider partners, patients, families and community members.

The way you engage around a system of care, regardless of whether it’s funded or unfunded, is of utmost importance to the success of this program.  There isn’t enough money in the program to build shiny new things, but the needs are very acute.  So, you have to work with providers and work to build a common communication infrastructure, work to align interests, fill service gaps, and make sure that we’re being smart and collaborative in how we help patients.

In Alaska, the goal is in part to be able to divert lower acuity patients away from the finite resources available to the more complex patients.  Individuals that need to exit the system should be moved back to their local community faster, which is often easier said than done.  So, external quality and review on top of that is a central piece to this.  Do you need someone externally to measure quality and see if services are being delivered properly?  It’s almost always a value add to have an extra set of eyes reviewing things as long as it’s done in a constructive, collaborative way.

So, I think the work we’ve done in other states will be a tremendous value to our proposed work in Alaska.