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Managing Managed Care Plans to Promote Physical-Behavioral Health Integration in States Open Access

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One option that state Medicaid programs interested in better integration of physical and behavioral health services have is to align payment of these services by using one Medicaid managed care contract. This option is consistent with a national trend toward moving more services and populations into Medicaid managed care in order to achieve better quality of care at a lower cost, and is therefore attractive to states. However, the success of that approach in driving better integration of physical and behavioral health services at other levels of the system depends on how the new Medicaid managed care contract is implemented. The states of Kansas and Texas both carved new behavioral health services into their Medicaid managed care contracts in 2013 or 2014 in an effort to promote better integration of physical and behavioral health services. This dissertation builds case studies using document review and interviews with state personnel, managed care plans, and providers/ advocates in order to understand how these two states employed their authority, policy incentives, and ideas to advance the goal of integrated care beyond the payment level. The goals of this research were to understand how these strategies were used to promote additional levels of integration in the state, including at the administrative level, the managed care plan level, and the clinician level (through enhanced coordination, collaboration, and/ or collocation of care), while continuing to advance the goal of maintaining beneficiary access to high quality behavioral health care through the managed care plans. Contextual barriers that existed in each state to make integration efforts more difficult were also examined.At the administrative level, Kansas was unable to integrate, due to implementation issues and the different goals held by the behavioral health and Medicaid agencies. Texas had a more successful approach, streamlining administration through their Medicaid agency but bringing key stakeholders in to advise the agency. At the managed care plan level, both states struggled with improving integration. Managed care plans did not fully utilize their position as a central hub for information about each beneficiary’s health care by providing needed information to the providers who were caring for them. They also did not clearly delineate care management responsibilities between themselves and providers. At the clinical level, successful efforts at clinical integration at the community mental health center (CMHC) level were spawned in both states by alternative payment strategies put in place by the managed care plans. Only one of the two states (Texas) contractually required this of their managed care plans, but efforts proliferated in both states. In Texas, the involvement of key stakeholders in the design and implementation of integration efforts was key to ensuring that all stakeholders were working toward common goals and was critical to the overall success of the state. A legislatively-appointed stakeholder body that issued recommendations regarding how oversight of the program should proceed was particularly effective because the recommendations were vetted by people at many different levels of the system.

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