Robert Wood Johnson Foundation: Depression in

Primary Care Initiative: National Meeting, Amelia

Island FL

Massachusetts Consortium on Depression in Primary Care (MCDPC) Demonstration

February 16, 2006

Challenges for Medicaid Plans

Thanks to: UMMS Team

Linda Weinreb, MD, PI Carole Upshur, EdD, Co-PI Gail Sawosik, MBA, Project Coordinator Deborah-Ruth Mockrin, LICSW, Care Manager Judith Savageau, MPH, Data analyst Ken Fletcher, PhD, Data analyst Dan O’Donnell, MD, MPH, Primary Care Consultant Sandy Blount, PhD, MH Integration Consultant Heidi Vermette, MD, (former Consulting Psychiatrist) Dan Kirsch, MD, Consulting Psychiatrist Elizabeth de la Rosa, Bilingual Care Manager Lorna Chiasson, DFMCH Administrative Staff Jianying Zhang, MS, CHPR Statistician for MassHealth claims data Ann Lawthers, ScD, CHPR research staff for MassHealth claims data

MassHealth Team

Annette Hanson, MD (former Medical Director), Co-PI Michael Norton, MSW, MassHealth Behavioral Health

Programs, Co-PI Louise Bannister, RN, JD, Director PCC Plan Phyllis Peters, MBA, Deputy Assistant Secretary, Acute

and Ambulatory Services Fran Slate, MS, Contract Manager, MCO Plan Kate Staunton Rennie, MPA, Deputy Director, PCC Plan Kate Willrich Nordahl, MS, Director MCO Plan Ron

Steingard, MD, Medical Director

Collaborating Health Plans

Massachusetts Behavioral Health Partnership

PCC Plan Boston Medical Center HealthNet Plan Neighborhood Health Plan Network Health

Issues for MCDPC

Plans had different arrangements around behavioral health—carve in, carve out, FFS, capitated; and these evolved during the demonstration time

Significant investment of plans collaborating was made possible by RWJF grant (e.g. monthly meetings); likely not sustainable

Major state budget and plan changes required staff time unrelated to the demonstration project

Significant leadership turnover, Medicaid office reorganizations, and need to defend a federal suit on children’s mental health during time of depression demonstration

Enrollments and over all risk (e.g. disabled members) shifted among plans during implementation period

Challenges to behavioral health integration found in MassHealth Plans

Failure of network administrators or plan behavioral health directors to appreciate the extent of patient access difficulties and difficulties for PCPs trying to access BH care on behalf of patients

Limited availability of urgent care appointments in behavioral health resulting in crisis care, ER visits

Up to 50% of patients don’t show up for BH appointments without follow up support

Patients ‘on paper’ were connected to behavioral health but not in fact

Behavioral health rules about compliance push patients out (e.g. if miss certain number of appointments, they will no longer be served)

Behavioral health providers, like primary care, don’t have chronic illness or patient management system in place

Both PCPs and behavioral health providers acknowledged there were no systems for communicating with each other; time investment to do this and lack of financial support for that time an issue as well as lack of guidelines, protocols, expectations

PCPs want

Sense that they can get patients connected to behavioral health without undue wait time (applies to both MassHealth and commercial payers)

Medication consultation on short notice/real time—phone or email ‘curbside consult’ without need to wait for patient referral process

Ability to make referral appointments for patients like other specialties

All payers need to be on same page about reimbursement for depression treatment

Needs to be way to work with same team of care manager, psychiatrists, therapists to address patient needs—difficult to develop multiple relationships

Intervention tried

Care Manager role CM or PCP office staff able to fax or call in appointment for patient; if BH provider

prefers patient to call, CM is notified if call takes place Information communicated back and forth from practice to BH provider by CM CM conducts routine follow-up; connects patient to plan based social case

management, transportation, community resources CM monitors all health care needs and keeps PCP informed CM collects data and follow up PHQ-9 scores

Systems changes in behavioral health: Urgent visits (within 2-3 days) available Some providers allocated priority BH slots to high volume primary care sites Regular intake and initiation of therapy within two weeks Psychiatry medication consultation within 1-2 weeks Patient asked to sign HIPAA release for CM and PCP practice BH providers have` information from PCP to assist with patient assessment

Sustainable solution across plans

Preferred providers convened along with PCP practice representatives from each plan

Lists of contact information, including ‘inside lines’ and what to do to reach clinician (either PCP or BH provider for patient) in an emergency distributed for practices and BH agencies

PCP practices identify an appointment liaison Preferred providers agree to accept appointments from PCP

practice, not just directly from patient PCP practices agree to provide PHQ score and other

information to the BH provider at time of referral for an appointment

BH providers agree to communicate to PCP practices if patient kept the appointment

BH providers agree to improve communication with PCP practices about patient progress (with appropriate consent)

Remaining challenges

How to set this process up across the state Define and continue role of BH network mangers to

link to PCPs Maintaining communication and connections

between PCPs and BH providers with staff turnover Addressing shortages of specific services, e.g.

bilingual therapists, and psychiatrists Sustaining learning from this project into the future

with potential changes in contracting language, new vendors etc. that result in leadership changes

Issues specific to Medicaid plans

Lack of continuity of insurance coverage-patients in and out of coverage in frequent cycles due to both administrative and patient factors

Rates paid to providers—both BH and PCP Biases by providers vis a vis Medicaid Hard to reach consumers (transient, lose of phones etc.) More diverse racially/ethnically/linguistically More psychosocial challenges that medical care can’t address

(food security, housing problems, disabilities, etc.) Less resources for self-management Less community-based support resources: cost and other barriers