September 2017 00US17EUB0001©2017 Otsuka America Pharmaceutical, Inc., Rockville, MD

TRENDS IN BEHAVIORAL HEALTH:A Reference Guide on the U.S. Behavioral

Health Financing & Delivery System

THE 2017 EDITION

Brought to you by

Over 43 million people in the United States suffer from a mental illness and more than 20 million Americans have an addictive disorder.1,2

The incidence of co-occurring mental illnesses and addictive disorders is high, requiring specialized treatment approaches. In 2014, behavioral health treatment expenditures totaled $220 billion.3 While treatment of these disorders is less than eight percent of total health care spending, the impact of these illnesses is far greater.3 Individuals with a behavioral disorder use at least two times more total health care resources than individuals without a behavioral disorder.4 And, behavioral health disorders also have a large socioeconomic and human impact on the nation as a whole. Improving the behavioral health delivery systems, in terms of care coordination, consumer access, and quality, is a critical component in improving the overall effectiveness and efficiency of the U.S. health care system.

To contribute to the work of the thousands of dedicated professionals in the health care field focused on issues related to behavioral health disorders, Otsuka America Pharmaceutical, Inc. (OAPI) and Lundbeck are pleased to share with you this first annual reference guide, Trends in Behavioral Health: A Reference Guide on the U.S. Behavioral Health Financing & Delivery System. OAPI and Lundbeck are engaged in a collaborative long-term global alliance agreement based on a shared heritage of research and development in neuroscience. We believe this collaboration will lead to new products that will have a positive impact on a broad range of behavioral health conditions improving the lives of millions of people. Lundbeck and OAPI always want to be at the cutting edge of the health care field. We empower our people to push the boundaries of creativity and convention.

Our goal with this reference guide is to make a positive contribution to the national conversation among key stakeholders, including commercial and government payers, integrated delivery networks, and providers, about the disproportionate effect of behavioral health disorders on the U.S. health care system, and the trends shaping the field. The guide includes an update on key national policies, a state-by-state landscape analysis, key metrics on behavioral health service delivery capacity and quality metrics, and a national survey of health plans on population health management approaches specific to individuals with complex support needs with behavioral disorders.

In this guide, you will discover that it is a vastly different landscape than prior to the implementation of the Affordable Care Act3, shaping the care for individuals with behavioral disorders. And, each year, our goal is provide an update on the complex equation that encompasses health care coverage and financing, care management options, and the availability and quality of services being delivered.

We hope you find the information in this reference guide valuable in advancing your good work, and we welcome your comments.

Sincerely,

Sean Phillips, Pharm. D. | Otsuka, Vice President Managed Markets

Brian McCarthy | Lundbeck, Vice President Managed Markets

FOREWORD

4 | TRENDS IN BEHAVIORAL HEALTH 4 | TRENDS IN BEHAVIORAL HEALTH

5| 5|

I. Executive Summary 6-7

II. National Behavioral Health System Landscape 8-15

• Executive Summary 8

• U.S. Health Care Coverage Trends 8-9

• Federal Behavioral Health Policy Initiatives 10-12

• Veterans and Behavioral Health Care 12-15

III. State Behavioral Health Financing and Service Delivery Systems 16-23

• Executive Summary 16

• State Behavioral Health Systems Typology Chart and Medicaid Behavioral Health Financing Arrangements 16-17

• State Behavioral Health Care Coverage and Reference Chart 19

• State Medicaid Financing Systems for the SMI Population 19

• State Innovation Initiatives and Reference Chart 20-23

IV. Health Plan Population Health Management 24-29

• Executive Summary 24

• Health Plan Current and Future Use of Analytics in Identification and Early Intervention of High Risk Consumers 24

• Health Plan Current and Future Use of Innovations in Improving Consumer Access to Behavioral Health Treatment Strategies 25-26

• Health Plan Current and Future Use of Behavioral Health Consumer Engagement Strategies 26

• Health Plan Current and Future Use of Models to Improve Coordination of Care for Consumers With Behavioral Health Conditions 27

• Health Plan Current and Future Use of Behavioral Health Strategies For Ensuring Quality of Care 28

• Health Plan Current and Future Use of Behavioral Health Provider Partnership Models 29

V. Consumer Access and Delivery of Care 30-37

• Executive Summary 30

• Consumer Access to Behavioral Health Care 30-33

• Behavioral Heath Care Quality 34-37

• The Centers for Medicare and Medicaid Services Quality Measures 37

VI. Additional Resources 38

VII. Sources 39-46

TABLE OF CONTENTS

6 | TRENDS IN BEHAVIORAL HEALTH

This 2017 first edition of Trends in Behavioral Health: A Reference Guide on the U.S. Behavioral Health Financing & Delivery System (The Guide) provides information and insights into the multi-layered United States behavioral health system. The Guide includes a snapshot of current statistics, current issues, and emerging trends in order to inform the discussions, debates and decision-making of policy-makers, payers, providers, advocates and consumers in today’s dynamic health care environment. It begins with the national policy context that is shaping the U.S. health and human services market – and by extension the behavioral health market. The Guide then focuses on the unique state behavioral health delivery systems that were created by a combination of historical practices, federal and state policy, and market factors over the past years. It also examines the practices of health plans that now manage the health care and behavioral health care for over 75% of the U.S. population. Finally, The Guide looks at behavioral health from the consumer perspective in terms of access to inpatient services, quality of care and the performance of the health plans in managing these services.

Overall, there are several trends that are having a profound impact on behavioral health financing, service system delivery and outcomes that are worth noting:

• National health care policy, specifically as related to Medicaid and Medicare, as well as current market trends establish the parameters for behavioral health financing and the behavioral health service delivery. With the majority of consumers with serious mental illness (SMI) covered by public payers, Medicaid and Medicare policy initiatives have the largest impact for this population.

• The national mental health market is moving towards a more comprehensive, value-based system of care. Federal policy is focused on developing better and more cost-effective use of available behavioral health funding to manage access, quality, and thus value of care. Alternative payment models, the end of the Institutions for Mental Disease (IMD) exclusion, coordination of care codes, and delivery system reform and modernization all seek to improve the delivery, integration, and reimbursement of care.

• Overall, health insurance coverage nationally has turned to managed care models to address cost, access, and quality of care. Virtually all individuals with commercial coverage and over 70% of individuals with coverage through Medicaid are in managed care plans. Currently, only about 30% of individuals with Medicare have opted into Medicare Advantage managed care plans.

• Medicaid is the primary payer for behavioral health services, and as the main payer serving the SMI population, state Medicaid programs serve as an important barometer for the behavioral health market. An examination of state-level policy finds two important trends – an increase in behavioral health financing integration into health plans and the emergence of consumer specific specialty health plans focused on the medical and behavioral health needs of the SMI population.

• State Medicaid programs have adopted a number of care coordination and integration initiatives that serve not only consumers with complex medical conditions, but also consumers with behavioral health conditions. There are 41 states with at least one behavioral health care coordination initiative including patient-centered medical home, health home, accountable care organization (ACO), dual demonstration, and certified community behavioral health clinic (CCBHCs) models.

EXECUTIVE SUMMARY

EXECUTIVE SUMMARY

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• Behavioral health integration is becoming a greater priority as the health care system improves consumer access, customer satisfaction, and consumer engagement. Payers and providers are increasingly managing high-cost and high-risk groups through population health management innovations that close the gap between members’ medical and behavioral needs through evidence-based practices and technologies that increase access to care and empower active individual participation in attaining health goals.

It is clear that national and state policies and practices have surpassed the initial efforts to advance behavioral health, underscoring a greater understanding of its effects on not just the cost of treatment, but more broadly on population health and wellness. The emergence of technology and evidentiary treatment models enable health systems to tailor value-based service delivery models that focus on the access and engagement needs of varying demography and chronic conditions. With these new provisions and innovations, there is more opportunity for person-centered and integrated high-quality health care to be placed firmly at the center of the new value equation.

8 | TRENDS IN BEHAVIORAL HEALTH

The United States (U.S.) system for the financing and delivery of behavioral health services is in a state of flux. The market factors contributing to the concurrent developments in behavioral health are a complex combination of national policy, the unique effects of state governance and regulation in the United States, and the many organizations participating in the health and human services industry.

This opening section looks at the key U.S. policy issues and national trends in the health care system that are the framework for the financing and delivery of behavioral health services. Among these many factors, there are a few with direct and significant impact on behavioral health.

Over the past five years, we have seen a shift in the population distribution among payers at the national level, with a 40% reduction in the uninsured population and an increase in the Medicaid population as a direct result of the Patient Protection and Affordable Care Act of 2010 (PPACA).1,2 The past five years have also seen a shift in the financial models being utilized by payers. The use of managed care financing models has increased in the nation by 24% across all payer types between 2011 and 2016 – with 76% of the total U.S. population enrolled in some form of managed care.3

While a number of factors have contributed to changes in the overall landscape of health care, many provisions of U.S. legislation and subsequent federal rules and regulations have had a large impact on the behavioral health care system in particular.4 These policy initiatives are designed to promote better coordination of care, a more value-based system, and more comprehensive treatment options for consumers.

The Patient Protection and Affordable Care Act of 2010 (PPACA) has shaped the health care system over the past decade. While a change in the political climate may result in changes to the health care system in the short-term future, the system has already been irrevocably shaped by the PPACA. Over the past five years, we have seen a shift in the population health insurance coverage distribution among payers at the national level, as well as a change in the financing delivery models being utilized by payers.1,5

Health Insurance CoverageThree major provisions of the PPACA legislation have influenced health care coverage throughout the country, and thereby changed the coverage map for consumers: the first was the option for states to expand their Medicaid programs to cover adults with income below 138% of the federal poverty level (FPL); the second was the creation of the health insurance marketplace, which allowed individuals and small businesses to shop for coverage; and third was the health insurance

NATIONAL BEHAVIORAL HEALTH SYSTEM LANDSCAPE

U.S. HEALTH CARE COVERAGE TRENDS

3%

3%

* Numbers may not add to 100%, as some consumers may have more than one type of health care coverage. For example, an individual may have primary commercial coverage from a private health plan and receive secondary coverage through Medicare.

U.S. Population 2011: 309,348,193

3%

3%

U.S. Population 2016: 323,127,513

Uninsured

Military

Medicare

Dual Eligibles

Medicaid

Commercial

54%

20%

9%

15%

52%

15%

15%

12%

U.S. Health Care Coverage, 2011 and 20161Figure 1

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Health Care Coverage and SMI PopulationThe health care coverage map for consumers with serious mental illness (SMI) differs from that of the general population. Consumers with SMI are defined as consumers age 18 and older with a diagnosable mental, emotional, or behavioral health disorder; meet the criteria specified in the Diagnostic and Statistical Manual of Mental Disorders; and the disorder results in serious functional impairment. A majority of mental, emotional, or behavioral disorders have the potential to be categorized as SMI; however, schizophrenia and bipolar disorder are most commonly associated with the term.8 Consumers with SMI are disproportionately served by public health care systems. As of 2014, the latest year SMI estimates are available, 58% of consumers with SMI were served by public insurance, 29% were served by private insurance, and 13% were uninsured. As a single payer, Medicaid has the largest proportion of SMI consumers at 32%. This percentage includes dual eligibles as Medicaid is the main payer of behavioral health services.9 Among different groups of consumers, the dual eligible population has the highest prevalence of SMI—an estimated 30% of the population has a diagnosis of SMI.10

Managed Care Financing ModelsBetween 2011 and 2016, the use of managed care financing models has increased in the U.S. by 24% across all payer types—with 76% of the total U.S. population enrolled in some form of managed care. The use of managed care has increased most substantially among public payers, increasing almost 60% between 2011 and 2016. Comparatively, private payer use of managed care increased 13% over the same period.3 This increase in managed care is due to a combination of factors, including a push to shift more services and populations to managed care financing models - and a desire from payers to delegate the management of care.11

Medicaid programs have seen the single largest increase (78%) in the number of consumers enrolled in managed care between 2011 and 2016. In 2011, 50% of the Medicaid population was enrolled in managed care, by 2016, 68% of the population was enrolled in managed care.3 The use of Medicaid managed care has increased for a number of reasons including the need to stabilize state Medicaid costs, the shift to cover high-need and high cost populations through managed care, and the expansion of Medicaid to adults with income below 138% of the federal poverty level (FPL).7,11 Medicare has seen a 52% increase in the use of managed care for enrollees, while the military population has actually seen a decrease of 17% in the use of managed care.3

70%

30%

mandate, which required all adults to have health insurance or pay a penalty.6,7 As a result of these three major system changes, there has been significant change in how Americans receive health insurance coverage. The uninsured population has decreased by 40% between 2011 and 2016, while Medicare, Medicaid, and commercial populations have all seen an increase in covered populations. Medicaid has seen the single largest increase in the population covered with enrollment increasing 38% in between 2011 and 2016.1

Dual Eligibles with SMI, 200910

Dual eligible population with SMI

Dual eligible population without SMI

Figure 2

29%

56%

Consumers with SMI

All Consumers

32%

20%

10%23%

13% 11% Uninsured

Military

Medicare non-dual

Medicaid

Commercial

Figure 3 U.S. Health Insurance Coverage For Consumers With SMI, 20143

*Numbers may not add to 100%, as some consumers may have more than one type of health care overage. For example, an individual may have primary commercial coverage from a private health plan and receive secondary coverage through Medicare.

2%3%

10 | TRENDS IN BEHAVIORAL HEALTH

Payer Type 2011 Percent of U.S. 2016 Percent of U.S 2011 Percent of Population 2016 Percent of Population

Population Covered3 Population Covered3 Enrolled in Managed Care3 Enrolled in Managed Care3

Commercial 52% 54% 93% 98%

Medicaid 18% 23% 50% 68%

Medicare 16% 18% 25% 33%

Military 3% 3% 57% 49%

Uninsured 15% 9% N/A N/A

Total 105% 107% 64% 76%

* Numbers may not add to 100%, as some consumers may have more than one type of health care coverage. For example, an individual may have primary commercial coverage from a private health plan and receive secondary coverage through Medicare.

While a number of factors have contributed to changes in the overall landscape of health care, many provisions of U.S. legislation and subsequent federal rules and regulations have had a large impact on the behavioral health care system.4 There are five major policy initiatives that will shape the mental health market over the next few years; these policy initiatives are designed to promote better coordination of care, a more value-based system, and more comprehensive treatment options for consumers.

Medicare Coordination of Care Codes

In January 2017, Medicare implemented a new coding and reimbursement system for behavioral health services integrated into primary care settings that are furnished via the Medicare psychiatric Collaborative Care Model (CoCM).12 The psychiatric CoCM allows for interprofessional consultation between a psychiatrist or behavioral health specialist and the primary care clinician. Previously, care coordination activities between a psychiatrist or behavioral health specialist and the primary care clinician were “bundled” into the evaluation and management visit codes used by all specialties.13 Provider organizations using psychiatric CoCM will bill using three G-codes (G0502, G0503, and G0504) until Current Procedural Terminology (CPT) codes are established possibly by 2018.14 Although, these new codes are unlikely to change the way provider organizations operate, it does signal an emphasis by Medicare on integration of behavioral and physical health.

Alternative Payment Models in Medicaid and Medicare

In January 2015, the federal Department of Health and Human Services announced a goal of tying 90% of Medicare fee-for-service payments to quality by 2018 and 50% of payments to cost and quality by 2018.15 Examples of advanced alternative payment models (APMs) currently being implemented by Medicare include Next Generation Accountable Care Organizations (ACOs), Comprehensive Primary Care Plus, and the Oncology Care Model. Additionally, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the sustainable growth rate for the Medicare physician fee schedule and replaced it with the Quality Improvement Program (QIP). Under QIP, clinical professionals will be required to participate in either advanced alternative payment models or the merit-based incentive program, which requires clinical professionals to report on quality in order to receive adjustments to their Medicare payments.16 At this time, QIP does not include behavioral health provider organizations; however, participating clinical professionals may choose to report on behavioral health measures including anti-depressant medication management and depression remission at 12 months.17 The Centers for Medicaid and CHIP Services has also issued encouragement to state Medicaid programs to implement alternative payment models. Examples of alternative payment models in Medicaid include ACOs, health homes, and episodes of care.18 In 2011, Missouri implemented a health home initiative for adults and children with SMI. Community mental health centers receive a per member per

FEDERAL BEHAVIORAL HEALTH POLICY INITIATIVES

Figure 4 Managing Care Financing Models

11|

month (PMPM) rate to provide the six health home model care coordination functions.19 As of January 2016, the program’s cost savings were $98 per member per month (PMPM) and emergency room visits per 1,000 were down 34%.20

Institutions for Mental Disease (IMD) Medicaid Exclusion

In April 2016, the Centers for Medicare and Medicaid Services (CMS) finalized new managed care rules for the Medicaid program. Under the new rules, Medicaid health plans are able to care for consumers of any age in an Institution for Mental Disease (IMD) for up to 15 days as an “in lieu of” service. Prior to this, state Medicaid programs were prohibited from receiving federal funding for the provision of services in a facility with more than 16 beds where beds are primarily used to serve those with a mental illness or substance use disorder. Adoption of this new rule is dependent upon whether the state utilizes health plans or behavioral health organizations. To enact the rule, states must include IMDs as an “in lieu of” of service in the health plan contract. Health plans are not required to provide the service and consumers may refuse service in an IMD.21

Parity Legislation

In 2008, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) required private group plans to provide parity for mental health and substance use disorder benefits. Two years later, the Patient Protection and Affordable Care Act (PPACA) required parity for individual and small group plans, and in 2016, both the Department of Defense (DoD) and the Centers for Medicare and Medicaid Services (CMS) released final rules extending mental health and substance abuse parity to the TRICARE and Medicaid populations respectively. Parity does not require plans to cover mental health and substance abuse benefits. Parity requires that when a health plan offers mental health and substance abuse benefits, those benefits may not be more restrictive than medical/surgical benefits. Restrictiveness is measured through financial requirements, quantitative treatment limits, and non-quantitative treatment limits. Although parity has been implemented fairly recently, it has been suggested that parity has improved treatment rates for mental health and substance use.22

Public Health Care Safety Net

For individuals with SMI who are uninsured, the public health safety-net also serves as an important resource for receiving care.2 The majority of care to the uninsured is provided

in hospital based settings, followed by publicly supported community provider organizations, and then office-based physicians.23 Under the PPACA and other federal initiatives, key changes are being made to how services are financed and delivered to individuals with SMI who are uninsured. First, under the PPACA, Disproportionate Share Hospital (DSH) payments to hospitals that serve a large number of low-income individuals are set to be reduced in fiscal year 2018. State Medicaid programs are statutorily required to make DSH payments to hospitals that serve a high proportion of Medicaid and low-income patients. These payments are limited by annual federal allotments and funding differs greatly by state. States may make DSH payments to IMDs covering unpaid costs of care for uninsured individuals age 21 to 64. While the DSH reductions have been postponed in the past, these Medicaid program funds represent an important funding source for hospitals, which total $18 billion in 2014.24

At the community-based provider level, the Substance Abuse and Mental Health Services Administration (SAMHSA) has implemented a demonstration program in eight states that creates Certified Community Behavioral Health Clinics (CCBHCs) authorized under Section 223 of the Protecting Access to Medicare Act (PAMA), which are required to serve all individuals on a sliding scale regardless of their ability to pay.25,26 CCBHCs are also eligible to receive enhanced Medicaid funding for reimbursable behavioral health services through the Prospective Payment System (PPS). Drawn from requirements on federally qualified health centers and other Medicaid programs, the CCBHCs are an important signal towards a nationally recognized mental health community-based provider system.27

Looking Forward at the Health Care Landscape

There are ongoing attempts to repeal or replace parts of the PPACA. Upon going to press with this report, the future of these legislative attempts is uncertain. Possible changes to the PPACA might include ending the Medicaid expansion, moving Medicaid financing to block grants or per capita funding, giving states more flexibility in running their marketplaces, imposing penalties on those who do not maintain continuous coverage, and substitute aged-based subsidies for means-based subsidies on the marketplace.28

In addition to reforms enacted by Congress, the federal Department of Health and Human Services (HHS) also has the opportunity to make smaller regulatory reforms that alter the PPACA. On February 17, 2017, the HHS released a proposed rule on the health insurance marketplace that truncates the

12 | TRENDS IN BEHAVIORAL HEALTH

The Veterans Administration (VA) provided health care services to 6.0 million veterans in 2015 or 69% of the total 9.6 million veterans eligible to receive health care services.31 The gap in coverage is due to the fact that many veterans have other forms of coverage, such as private insurance, TRICARE, Medicare, etc.32

The VA is an integrated health care system providing the majority of health care services in VA operated medical centers and outpatient sites.33 The system breaks the country into Veterans Integrated Service Networks (VISNs), which oversee the operation of VA facilities in its defined geographic region.34 The VA provides a full continuum of mental health services including inpatient, outpatient, and specialized treatment for post-traumatic stress disorder (PTSD).35 In the past ten to 15 years, the VA has increased the number of facilities offering outpatient care. In 1995, the VA issued a directive to expand the number of community-based outpatient clinics (CBOC). The clinics could either be operated by the VA or contracted to a private clinic, group practice, or single practitioner. At the time of the directive there were 172 hospitals and 175 CBOCs. The majority of clinics were opened between 1998 and 1999 when 124 new CBOCs were opened.36 In 2016, there were over 755 CBOCs and 144 hospitals.37

Over the past ten years, the number of veterans receiving mental health care through the VA has increased from 900,000 in 2006 to 1.52 million in 2015. This is an increase of 69%. The majority of that increase in mental health care came between 2006 and 2010, when care increased by 74%. After 2010, the number of veterans receiving mental health care stabilized around 1.55 million.38

open enrollment period, amends standards for the special enrollment period, returns network adequacy standards to the states, and increases the de minimis variation between some health plan medal levels.29 A letter from the Secretary of HHS and the CMS Administrator also indicate changes to state Medicaid programs including, a faster more transparent process for waivers and state plan amendments, supporting innovative approaches to increase employment and community engagement, and aligning Medicaid and private insurance policies for non-disabled adults.30

In 2012, the VA found that there were longer than acceptable wait times for accessing mental health services and that VA tracking of wait times was inaccurate. VA standards state that veterans must be seen for an initial evaluation within 24 hours and a comprehensive diagnostic and treatment planning evaluation within 14 days.39 In the past two years, the VA has made very little progress in lowering mental health wait times. As of October 2014, when the VA began publicly reporting wait times, the average wait for mental health treatment was 4.11 days and in March 2017, the average wait time was 4.06 days.40

In order to alleviate staffing problems, the VA implemented a mental health hiring initiative in 2012. The initiative’s goal was to bring all facilities up to the VA average of 7.72 full-time clinical mental health staff (FTE) per 1,000 patients.41 As of 2016, some facilities are still working to reach this goal. By 2021, VA analysis finds that an additional 3,712 FTE mental health clinical staff will be needed.42

In order to address these issues, the VA implemented the Veterans Choice Program, which allows veterans who are not able to schedule an appointment within 30 days of their preferred date, within the clinically appropriate time frame, or on the basis of their residence to schedule an appointment with a provider organization outside of the VA.43

VETERANS AND BEHAVIORAL HEALTH CARE

Figure 5a

20

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VISN 1: VA New England Healthcare SystemVISN 2: New York/New Jersey VA Health Care NetworkVISN 4: VA HealthcareVISN 5: VA Capitol Health Care NetworkVISN 6: VA Mid-Atlantic Health Care NetworkVISN 7: VA Southeast NetworkVISN 8: VA Sunshine Healthcare NetworkVISN 9: VA MidSouth Healthcare NetworkVISN 10: VA Healthcare SystemVISN 12: VA Great Lakes Health Care SystemVISN 15: VA Heartland NetworkVISN 16: South Central VA Health Care NetworkVISN 17: VA Heart of Texas Health Care NetworkVISN 19: Rocky Mountain NetworkVISN 20: Northwest NetworkVISN 21: Sierra Pacific NetworkVISN 22: Desert Pacific Healthcare NetworkVISN 23: VA Midwest Health Care Network

Figure 5a Veterans Integrated Service Network Map44

8

8

21

Philippines Islands Guam

American Samoa Puerto Rico

US Virgin Islands

HI

WA

MT ND

SD

NE

KS

OK

TX

NM

CO

WY

UT

AZ

OR

CA

NV

NY

PA

WVOH

MI

INIL

WI

MN

IA

KYVA

NC

ME

TN

FL

MO

AR

LA

MS AL GA

SC

ID

20

19

19

17

22

2312

10

15

16

7

96

5

4

2

1

CT

VTNH

MA

RI

MDDC

21

NJ

DE

14 | TRENDS IN BEHAVIORAL HEALTH

VISN 1 2 4 5 6 7 8 9

States Served*

CT, MA, ME, NH RI, VT

NJ, NY, PADE, NJ PA, WV

MD, VA, DCNC, SC VA, WV

AL, GA, SCFL, GA PR, VI

AL, AR, GA IN, KY, OH TN, VA, WV

Number Users with Possible Mental Illness 88,075 98,657 100,875 44,927 135,044 158,283 190,943 113,451

Medical Centers 11 14 10 8 7 9 7 7

Outpatient Clinics 4 1 1 2 7 8 14 7

Community-basedOutpatient Clinics 40 59 44 27 28 47 51 39

Psychiatrists 239 249 150 120 221 256 379 147

Mental HealthNurse Practitioners 10 13 2 8 3 5 25 7

Number of Veterans who Accessed

Mental Health Services65,291 31,521 74,434 40,864 107,157 124,304 154,116 82,494

Average Wait Time for Mental Health Care

(days to appointment)3.24 2.97 4.07 4.73 5.34 5.5 3.61 3.86

* AL – Alabama, AK – Alaska, AZ – Arizona, AR – Arkansas, CA – California, CO – Colorado, CT – Connecticut, DE – Delaware, FL – Florida, GA – Georgia, HI – Hawaii, ID – Idaho, IL – Illinois, IN – Indiana, IA – Iowa, KS – Kansas, KY – Kentucky, LA – Louisiana, ME – Maine, MD – Maryland, MA – Massachusetts, MI – Michigan, MN – Minnesota, MS – Mississippi, MO – Missouri, MT – Montana, NE – Nebraska, NV – Nevada, NH – New Hampshire, NJ – New Jersey

Figure 5b Veterans Health Administration45

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10 12 15 16 17 19 20 21 22 23

IN, KY, OHIA, IL, IN MI, WI

AR, IL, KS KY, MO

AL, AR, FL LA, MO, MS

TXOK, NM, TX

CO, ID, KS MT, NE, NV

UT, WY

AK, ID, MT OR, WA

CA, NV, HI PH, GU, AS

AZ, CA CO, NM

IA, IL, KS MN, MO, ND NE, SD, WI

WY

154,019 90,848 82,721 183,057 136,834 69,013 101,185 91,135 185,406 91,240

12 8 9 9 5 3 6 8 4 2

2 38 5 1 19 20 11 26 12 2

59 8 52 49 30 51 34 23 58 59

251 176 99 196 205 133 147 193 312 146

21 1 6 6 1 1 17 8 9 6

64,899 62,448 60,945 143,119 91,581 53,345 70,960 74,565 101,437 64,626

3.18 3.79 3.78 3.87 4.93 4.21 3.07 4.42 5.23 3.22

NM – New Mexico, NY – New York, NC – North Carolina, ND – North Dakota, OH – Ohio, OK – Oklahoma, OR – Oregon, PA – Pennsylvania, RI – Rhode Island, SC – South Carolina, SD – South Dakota, TN – Tennessee, TX – Texas, UT – Utah, VT – Vermont, VA – Virginia, WA – Washington, WV – West Virginia, WI – Wisconsin, WY – Wyoming, AS – American Samoa, DC – District of Columbia, GU – Guam, PH – Philippines Islands, PR – Puerto Rico, VI – Virgin Islands

16 | TRENDS IN BEHAVIORAL HEALTH

STATE BEHAVIORAL HEALTH FINANCING AND SERVICE DELIVERY SYSTEMS

Medicaid is a primary payer for behavioral health services, accounting for 25% of the $186 billion spent on mental health (excluding addiction) in 2014.1 Consumers with serious mental illness (SMI) are disproportionately served by the public health system, with Medicaid serving a large portion (32%) of those consumers, including dual eligibles.2

As a primary payer for behavioral health services, and as the main payer serving the SMI population, state Medicaid programs serve as an important barometer for the behavioral health market. Since each state’s Medicaid program is unique— with different benefits and coverage options, different populations eligible for benefits, and different financing and delivery systems—examining the similarities and variation in state-level financing and delivery systems offers better insight into the initiatives shaping the behavioral health market.

Since 2011, state Medicaid programs have increasingly moved toward integrated financing models for behavioral health services. Between 2011 and 2017, the number of states with primary behavioral health carve-outs either to governmental entities or private managed care entities decreased. Conversely, during that time period, the percentage of states with behavioral health financing integrated in private health plans increased from 25% to 40%.3

Financing arrangements for services for consumers with SMI have also moved toward integrated managed care. In 2017, 28 states required consumers with SMI to enroll in a Medicaid managed care program; 18 states required these consumers to enroll in a Medicaid fee-for-service (FFS) plan; and in three states, the population was split between managed care and FFS.4

In addition to greater integration in financing models, states have also looked for better ways to coordinate benefits and services for consumers. In 2017, there were 41 states with at least one behavioral health care coordination initiative. In total there were 33 states with patient-centered medical homes (PCMHs)5, 21 states with health homes6, 12 states with dual eligible demonstration programs7,8, 11 states with Medicaid accountable care organizations (ACOs)9,10, and eight states participating in the Certified Community Behavioral Health Clinic (CCBHC) demonstration.11

There are two key factors that characterize the Medicaid behavioral health market— who is being served and how behavioral health services are financed. All states are required to cover children, parents/caretaker relatives, pregnant women, and the disabled and aged populations.12,13 States have the choice under the Patient Protection and Affordable Care Act (PPACA) to expand Medicaid to non-disabled adults with income below 138% of the federal poverty level (FPL). In states that have adopted Medicaid expansion, this population is served by Medicaid, in non-expansion states this population is most likely uninsured.14

How behavioral health services (excluding pharmacy) are financed determines how consumers receive care, how provider organizations are contracted, and how states pay for these services. There are five behavioral health financing arrangements that states typically use, and often states use more than one arrangement to serve different populations. Those five arrangements include: behavioral health services

STATE BEHAVIORAL HEALTH SYSTEMS TYPOLOGY CHART

in primary carve-outs to behavioral health organizations (BHOs), behavioral health services in primary carve-outs to governmental/regional BHOs, behavioral health services in private health plans, behavioral health services in the Medicaid FFS system, and behavioral health services in consumer-specific specialty health plans (medical and behavioral).3

When taken together, the Medicaid expansion option and the five behavioral health financing alternatives result in ten overarching behavioral health system typologies. The most common model is Medicaid expansion and integration of behavioral health financing into Medicaid health plans. The second most common arrangement is Medicaid expansion with behavioral health financing remaining in the Medicaid FFS plan.3

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Medicaid Behavioral Health Financing Models, % of States, 2011-20173

5%

Medicaid Behavioral Health Financing Model Definitions3

A carve-out is a managed care financing model where some portion of benefits—dental services, pharmacy services, behavioral health services, etc.—are separately managed and/or financed.15

1. Primary carve-out to private BHOs – State Medicaid program delegates some or all behavioral health benefits to a separate private behavioral health organization (BHO) that is at-risk for this subset of services.3

2. Primary carve-out to governmental/regional BHO – State Medicaid program delegates some or all behavioral health benefits to a separate governmental or BHO that is at-risk for this subset of services.3

3. Behavioral health service financing in private health plan – Medicaid program contracts with private health plans who are responsible for all behavioral health services, as well as, physical health services.3

4. Behavioral health in Medicaid FFS plan – The state Medicaid program retains responsibility for some or all behavioral health benefits without delegation to a separate management entity. Other Medicaid services may also be delivered through the Medicaid FFS plan or through a health plan.3

5. Consumer-specific specialty health plan – State Medicaid program delegates responsibility for all benefits (physical health and behavioral health) for consumers with behavioral health disorders (or other specific disorders or needs) to a specialty Medicaid health plan.3

There are two key factors that characterize the Medicaid behavioral health market — who is being served, and how behavioral health services are financed.

MEDICAID BEHAVIORAL HEALTH FINANCING ARRANGEMENTS

Although states often use more than one carve-out arrangement to serve different populations and these arrangements shift over the years, there is a clear trend showing the decline of primary carve-outs to both private entities and regional/governmental entities. Between 2011 and 2017, the number of states with primary carve-outs to governmental/regional entities and to private managed care entities decreased. During the same period, the percentage of states with behavioral health financing integrated into private health plans increased from 25% to 40%.3

One other major change occurring in state Medicaid behavioral health financing arrangements is the use of the consumer specific carve-out. In a consumer-specific carve-out, the state delegates care of a specific population to a specialty Medicaid health plan rather than delegating specific services.18 There are three states with this model—Arizona, Florida, and New York. An example of this is the Magellan Complete Care in Florida, which finances services and coordinates care for the SMI population.4,19

Behavioral Health In Consumer- Specific Specialty Health Plans (Medical & Behavioral)

Behavioral Health In FFS Medicaid Plan

Behavioral Health Services In Private Health Plans

Behavioral Health In Primary Carve-Outs To Governmental/Regional Entities

Behavioral Health In Primary Carve-Out To Private Entities

13%

2011

Figure 6

11%

25%

51%

19%

11%

32%

39%

9%

9%

36%

41%

10%

40%

37%

8%

2013 2016 2017

*Numbers may not add to 100%

5%

18 | TRENDS IN BEHAVIORAL HEALTH

Behavioral Health Financing Arrangement*3

Medicaid Expansion (32 states)16 Non-Medicaid Expansion (19 states)16

Behavioral Health InPrimary Carve-Out To

Private BHOs

4 States 1 State1. Arizona - Acute Care Program2. Colorado3. Hawaii - SMI Population4. Massachusetts – Primary Care Case Management Program

1. Idaho

Behavioral Health In Primary Carve-Outs To

Governmental/Regional BHOs

4 States 2 States1. California2. Michigan3. Pennsylvania4. Washington - All Counties, except Clark & Skamania

5. North Carolina6. Utah

Behavioral Health ServiceFinancing Integrated Into

Private Health Plans

18 States 7 States1. Arizona – Acute Care

Dual Eligibles Program2. Arizona – Long-Term Care3. Hawaii4. Illinois5. Iowa6. Kentucky7. Louisiana8. Massachusetts

– Managed Care Program9. Minnesota

10. Nevada 11. New Hampshire12. New Mexico13. New York14. North Dakota – Medicaid

Expansion Population15. Oregon16. Rhode Island17. Washington – Clark and

Skamania Counties18. West Virginia

1. Florida2. Georgia3. Kansas4. Nebraska5. South Carolina6. Tennessee7. Texas

Behavioral Health Financing In FFS Medicaid Plan

12 States and DC 10 States1. Alaska2. Arkansas3. Connecticut4. Delaware5. District of Columbia6. Indiana7. Maryland

8. Montana9. New Jersey10. New York – Long-Term Care11. North Dakota12. Ohio*13. Vermont

1. Alabama2. Florida

– Long-Term Care3. Maine4. Mississippi5. Missouri

6. Oklahoma7. South Dakota8. Virginia9. Wisconsin10. Wyoming

Behavioral Health InConsumer-Specific

Specialty Health Plan

2 States 1 State1. Arizona - SMI Population2. New York - SMI Population

1. Florida - SMI Population

*States are italicized to denote that they are listed more than once because the state utilizes multiple financing arrangements.

STATE BEHAVIORAL HEALTH PHARMACY FINANCING ARRANGEMENTS

Some states use different financing arrangements for behavioral health benefits and behavioral health pharmacy. Financing arrangements for behavioral health pharmacy differ slightly than those for behavioral health benefits. Pharmacy behavioral health financing arrangements include, managed FFS by state, integration into the private health plan, and primary carve-out

to the BHO. Like behavioral health benefits, mental health pharmacy benefits can be delivered through multiple financing arrangements in each state. In total, there are 34 states with behavioral health pharmacy integrated into the private health plan, 24 states with FFS, and two states with a primary carve-out to a BHO.17

19|

Managed FFS By State

1. Alabama2. Alaska3. Arkansas4. Colorado5. Connecticut6. Idaho7. Maine8. Massachusetts

– Primary Care Case Management Program

9. Montana10. North Carolina11. North Dakota12. Oklahoma13. South Dakota14. Vermont15. Wyoming16. California17. Maryland18. Michigan

19. Oregon20. Utah21. Florida

– Long-Term Care22. Missouri23. New York

– Long-Term Care24. Tennessee25. Wisconsin

Primary Carve-Out To BHO

1. Arizona – Acute Care Program 2. Hawaii – SMI Population

Carve-In To Private Health Plan

1. Arizona – Acute Care Dual Eligibles

2. Arizona – Long-Term Care

3. Arizona – SMI Population

4. Delaware5. District of Columbia6. Florida7. Florida – SMI

Population8. Georgia9. Hawaii10. Illinois11. Indiana12. Iowa

13. Kansas14. Kentucky15. Louisiana16. Massachusetts

– Managed Care Program

17. Minnesota18. Mississippi19. Nebraska20. Nevada21. New Hampshire22. New Jersey23. New Mexico24. New York

25. New York – SMI Population

26. North Dakota – Medicaid Expansion Population

27. Ohio28. Pennsylvania29. Rhode Island30. South Carolina31. Texas32. Virginia33. Washington34. West Virginia35. Michigan

STATE HEALTH CARE COVERAGE

Health care coverage varies across the country based on the characteristics of the state’s population — including unemployment rates, socioeconomic status, and other demographic factors — and on state-level policies. In particular, the Patient Protection and Affordable Care Act of 2010 (PPACA) has affected how many Americans receive health insurance coverage, through the federal essential health benefit, parity requirements, state-based heath insurance marketplaces, and Medicaid expansion.

In general, states that have expanded Medicaid have a lower uninsured population and a higher percentage of their population enrolled in Medicaid. Among the 32 states that have expanded Medicaid, in 2015 the average uninsured rate is 7%, with Massachusetts having the lowest uninsured rate at about 3% of the state population and Alaska having the highest

uninsured population at about 15%. Among the 19 states that have not expanded Medicaid, the average uninsured rate is 11%, with Wisconsin (which has a partial Medicaid expansion) having the lowest uninsured rate at about 6% of the state population and Texas having the highest uninsured population at about 18%.16

Medicaid coverage across the country ranges from a high of 25% of the population in New Mexico (a state that expanded Medicaid), to a low of 7% of the total population in Utah (a state that did not expand Medicaid). Across most states, the largest percentage of the population has commercial insurance coverage (employer-sponsored or other private insurance). Utah, one of the state’s with the lowest rate of Medicaid coverage, has the highest percentage of their population enrolled in commercial coverage at about 69%.16

State Medicaid Behavioral Health Pharmacy Financing Arrangements, 201717Figure 7

VT NH MA CT RI NJ DE MD DC

WA

MT ND

SD

NE

KS

OK

TX

NM

CO

WY

UT

AZ

OR

CA

NV

NY

PA

WV

OH

MI

INIL

WI

MN

IA

KYVA

NC

ME

TN

FL

MO

AR

LA

MS AL GA

SC

ID

FFS financing

Integrated into private health plans

Multiple arrangements

AK

HI

20 | TRENDS IN BEHAVIORAL HEALTH

State Medicaid Expansion Total Population Medicaid % Dual Eligibles % Medicare % Military % Commerical Insurance % Uninsured %

Alabama Yes 4,863,000 13% 4% 14% 3% 57% 9%

Alaska No 741,894 12% 2% 8% 9% 54% 15%

Arizona Yes 6,931,071 17% 3% 13% 2% 52% 11%

Arkansas Yes 2,988,248 18% 4% 14% 2% 53% 9%

California Yes 39,250,017 21% 4% 9% 2% 56% 8%

Colorado Yes 5,456,574 16% 2% 12% 4% 58% 8%

Connecticut Yes 3,576,452 16% 5% 11% 1% 61% 6%

Delaware Yes 952,065 16% 3% 13% 2% 61% 5%

District of Colombia Yes 681,170 24% 4% 6% 2% 61% 3%

Florida No 20,612,439 13% 4% 15% 3% 52% 13%

Georgia No 10,310,371 13% 3% 11% 3% 56% 14%

Hawaii Yes 1,428,557 15% 3% 12% 9% 57% 4%

Idaho No 1,683,140 12% 3% 14% 2% 57% 11%

Illinois Yes 12,801,539 16% 3% 12% 1% 62% 7%

Indiana Yes 6,633,053 15% 3% 14% 1% 58% 10%

Iowa Yes 3,134,693 13% 3% 15% 1% 63% 5%

Kansas No 2,907,289 10% 2% 14% 3% 32% 9%

Kentucky Yes 4,436,974 19% 4% 15% 3% 53% 6%

Louisiana Yes 4,681,666 17% 5% 12% 2% 52% 12%

Maine No 1,331,479 15% 7% 15% 2% 53% 8%

Maryland Yes 6,016,447 13% 2% 11% 3% 64% 6%

Massachusetts Yes 6,811,779 15% 4% 11% 1% 66% 3%

Michigan No 9,928,300 15% 3% 15% 1% 61% 6%

Minnesota No 5,519,952 13% 3% 14% 1% 65% 5%

Mississippi No 2,988,726 18% 5% 13% 3% 48% 13%

Missouri No 6,093,000 11% 3% 15% 2% 59% 10%

Figure 8 State Health Care Coverage Reference Chart16

STATE MEDICAID FINANCING SYSTEMS FOR THE SMI POPULATION

Federal law requires Medicaid programs to cover certain populations including those receiving Supplemental Security Income (SSI), pregnant women, low-income children, and low-income families.12 Many consumers with serious mental illness (SMI) are eligible for SSI. Based on 2015 data from the Social Security Administration (SSA), about 34.8% of the 10.2 million consumers eligible for SSI benefits qualified on the basis of a mental health diagnosis (substance use disorders are not a qualifying condition).20

How a consumer qualifies for Medicaid determines what financing arrangement they receive health care services through—fee-for-service (FFS), managed care, or a choice of the two. Some states exclude the aged, blind, and disabled (ABD), or SSI population from managed care. No state excludes consumers from managed care based on a specific behavioral health diagnosis.

In 2017, 18 states required consumers eligible for disability benefits, including persons with SMI, to enroll in a Medicaid FFS plan; 28 states required enrollment in the Medicaid managed care program; and in three states the population was split between managed care and FFS. The split between managed care and FFS programs may be due to voluntarily enrollment for the SMI population or the geographic availability of managed care. Within the managed care program, consumers may be enrolled in a specialty managed care program that exclusively serves the SMI population or a specialty managed care program that serves the ABD population. In 2017, there were three states—Arizona, Florida, and New York—that enrolled consumers in a consumer-specific specialty plan for SMI and five states with a specialty plan for the ABD population—Indiana, Minnesota, Rhode Island, Texas, and Wisconsin.4

21|

State Medicaid Expansion Total Population Medicaid % Dual Eligibles % Medicare % Military % Commerical Insurance % Uninsured %

Montana Yes 1,042,520 12% 3% 16% 3% 54% 12%

Nebraska No 1,907,116 9% 2% 14% 3% 65% 8%

Nevada Yes 2,940,058 13% 2% 12% 3% 58% 12%

New Hampshire Yes 1,334,795 10% 3% 16% 2% 63% 6%

New Jersey Yes 8,944,469 13% 2% 13% 1% 63% 8%

New Mexico Yes 2,081,015 25% 4% 13% 3% 43% 11%

New York No 19,745,289 21% 4% 11% 1% 56% 7%

North Carolina Yes 10,146,788 14% 3% 14% 4% 53% 11%

North Dakota Yes 757,952 8% 2% 13% 3% 67% 7%

Ohio No 11,614,373 17% 3% 14% 1% 59% 6%

Oklahoma Yes 3,923,561 15% 3% 14% 3% 51% 14%

Oregon Yes 4,093,465 19% 3% 15% 1% 55% 7%

Pennsylvania No 12,784,227 14% 3% 15% 1% 61% 6%

Rhode Island No 1,056,426 18% 4% 14% 2% 57% 6%

South Carolina No 4,961,119 14% 3% 16% 4% 52% 11%

South Dakota No 865,454 10% 2% 15% 3% 60% 10%

Tennessee No 6,651,194 16% 4% 13% 2% 56% 10%

Texas Yes 27,862,596 12% 3% 10% 3% 55% 18%

Utah No 3,051,217 7% 1% 10% 2% 69% 11%

Vermont Yes 624,594 21% 5% 15% 2% 54% 4%

Virginia Yes 8,411,808 8% 2% 12% 7% 62% 9%

Washington No 7,288,000 17% 3% 13% 4% 57% 7%

West Virginia Yes 1,831,102 21% 5% 18% 2% 49% 6%

Wisconsin No 5,778,708 13% 3% 15% 1% 63% 6%

Wyoming No 585,501 8% 2% 14% 3% 61% 12%

FFS Managed CareSplit Between Managed

Care and FFS

Specialty Managed Care

for SMI Population

Specialty Managed Care

for ABD Population

1. Alabama2. Alaska3. Arkansas4. Colorado5. Connecticut6. District of

Columbia7. Georgia8. Idaho9. Maine

10. Missouri11. Montana12. North Carolina13. North Dakota14. Oklahoma 15. South Dakota16. Vermont17. West Virginia18. Wyoming

1. Delaware2. Hawaii3. Iowa4. Kansas5. Kentucky6. Lousiana7. Maryland8. Michigan9. Mississippi10. Nebraska11. New Hampshire

12. New Jersey13. New Mexico14. Ohio15. Oregon16. Pennsylvania17. South Carolina18. Tennessee19. Utah20. Virginia21. Washington

1. Illinois2. Massachusetts 3. Minnesota4. Nevada

1. Arizona2. Florida3. New York

1. Indiana2. Rhode Island3. Texas4. Wisconsin

Figure 9 Primary Financing System for the SMI Population, 20174

*The sums in the tables and charts may equal more than 100%, due to consumers enrolled in multiple plans.

22 | TRENDS IN BEHAVIORAL HEALTH

Figure 10 State Behavioral Health Innovation Initiatives Reference Chart

State Behavioral Health Innovation Initiatives, 2016-2017

STATE AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI

Certified Community Behavioral Health

Clinics 201711

Medicaid Accountable Care Organizations

2016-20179,10

X X X X

Medicaid Health Homes 2016-20176 X X X X X X X

Patient-Centered Medical Homes

2016-20175

X X X X X X X X X X X X

Dual Eligible Demonstration 2016-20177,8

X X X X X

1. Medicaid Patient Centered Medical Homes (PCMHs)

A model of care, not a physical place, PCMHs provide enhanced primary care to patients via the provision of comprehensive care, use of patient-centered care, care coordination, enhanced access, and a focus on quality and safety.21

STATE BEHAVIORAL HEALTH INNOVATION INITIATIVES

Over the past decade, state Medicaid programs have adopted a number of care coordination and integration initiatives that serve not only consumers with complex conditions, but also consumers with behavioral health conditions. These initiatives range from state designed and implemented initiatives to federal programs that states have the option to implement. Some of the most common behavioral health initiatives include:

2. Health Homes

Created under the PPACA, the health home model provides whole-person care coordination via the six health home services. Services are available to consumers with two or more chronic conditions; consumers with one chronic condition and at-risk for another; or consumers with serious mental illness.22

3. Medicaid Accountable Care Organizations (ACOs)

Initially created by the PPACA for Medicare, state Medicaid programs are adopting ACO-like models.23 Under this model, provider organizations form an agreement to provide care coordination and deliver services for a specific population. ACO performance is measured against financial and quality benchmarks.9

In 2017, there were 41 unique states with at least one behavioral health care coordination initiative. In total there were eight states participating in CCBHCs11, 11 states with Medicaid ACOs9,10, 21 states with health homes6, 33 states with PCMHs5, and 12 states with dual eligible demonstration programs.7,8

23|

MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SC TN TX UT VT VA WA WV WI WY

X X X X X X X X

X X X X X X X

X X X X X X X X X X X X X X

X X X X X X X X X X X X X X X X X X X X X

X X X X X X X

4. Dual Eligible Demonstrations

The financial alignment initiative, more commonly known as the dual eligible demonstration, integrates care delivery models for physical health, behavioral health, and long-term services and supports for the dual eligible population. States may either implement a capitated model where health plans receive a blended capitated rate from Medicare and Medicaid to administer services or a managed fee-for-service model where payment, provider networks, and administration remains the same, but quality improvement initiatives are implemented.24

5. Certified Community Behavioral Health Clinic (CCBHCs)

Established as part of the Protecting Access To Medicare Act (PAMA) of 2014, the CCBHC demonstration will run from 2017 to 2019. Under the demonstration, states certify behavioral health provider organizations as CCBHCs, which will use a prospective payment system for Medicaid reimbursement.25

24 | TRENDS IN BEHAVIORAL HEALTH

Over the past several years, the health care system has been driven by the pursuit of three goals: improving the health care of the population as a whole, improving the consumer care experience, and reducing the per capita cost of health care – also known as the “triple aim.”1 In accordance with these goals, health plans have developed new population health management strategies that focus on improving consumer access to care, consumer engagement, care coordination for consumers with behavioral health conditions, and quality of care in behavioral health.2

Many of these new strategies are focused on addressing the support needs of consumers with complex care conditions who are the 5% of the population using almost half of U.S. health care resources.3 To identify these consumers, health plans are increasingly using analytic capabilities for population segmentation. Over 90% of health plans are using analytic tools to identify complex consumers – and 94% of health plans are using analytics to identify consumers with serious mental illnesses.2

Using population segmentation data, health plans are adopting a wide range of strategies to improve the health outcomes and better manage the resource use of complex consumers with behavioral conditions.2

In addition to implementing targeted strategies for managing high needs consumers with behavioral health conditions, the provider reimbursement models used by health plans are also changing. Health plans are linking reimbursement to improved value – focused on reducing costs while improving health outcomes.4

As we move into a new era of health care, built on value and enhanced care coordination, the use of data and analytics is key to improving financial and clinical outcomes. Through a combination of clinical, financial, and operations data, payer and provider organizations can utilize analytics to segment consumers and stratify risk to help understand the needs of the population so that services can be better planned and delivered. Once segmented, best practice interventions can be targeted to meet the needs of a specific population.5

Across all payer groups, Medicare, Medicaid, and commercial, health plans have widely adopted the use of analytics for

HEALTH PLAN POPULATION HEALTH MANAGEMENT

All Health Plansn=750

HEALTH PLAN CURRENT AND FUTURE USE OF ANALYTICS IN IDENTIFICATION AND EARLY INTERVENTION OF HIGH RISK CONSUMERS

identification and early management of consumers in need of behavioral health interventions. Over 90% of all health plans report the use of analytics for identification and early management of high-risk consumers in need of behavioral health interventions. Nearly 95% report use of analytics for identification and early management of consumers with serious mental illness (SMI). These numbers are indicative of the greater depth of understanding and acceptance by health plans that behavioral health conditions greatly impact the health and wellness of the populations they manage.2

Figure 11 Use of Analytics in Identification and Early Management of High-Risk Consumers in Need of Behavioral Health Interventions, by Plan*2

Currently Implemented

Will Use In Future

Not Planned

*TRICARE and Medicare-Medicaid health plans are included in all health plan responses; however, due to low response rate, these plan types are not illustrated as subcategories nor included with other health plan types.

93.1%

92.3%

93.6%

94.7%

Medicaren=337

Medicaid n=141

Commercialn=246

5.3%

0.9%

1.4%

2.4% 2.8%

5.0%

6.8%

1.6%

25|

Consumer access to services is a critical component to achieving positive health outcomes. Access to services is determined not only by the ability to gain entry into the health care system, the geographic location of services, and availability of clinical professionals to meet the needs of the consumer – but also access to high quality evidence-based care.6 New innovations in service delivery seek to improve consumer access to behavioral health treatment by closing gaps in care and alleviating health care costs. 7 Innovations fall into two main categories, technology-based solutions and community-based treatment solutions. Technology-based interventions include tools such as telemental health, online therapy, and consumer portals.7,8

Among health plans, telemental health services are the most widely adopted technology-based innovation, with more than 96% of health plans reporting that they currently utilize telemental health services.2 This widespread adoption points to an increasing market maturity and less restrictive state

HEALTH PLAN CURRENT AND FUTURE USE OF INNOVATIONS IN IMPROVING CONSUMER ACCESS TO BEHAVIORAL HEALTH TREATMENT

reimbursement policies. These factors, in combination with workforce shortages among psychiatrists and studies that demonstrate positive telemental health outcomes, have led to widespread acceptance of telemental health as an effective means of service delivery to behavioral health consumers.9

The use of eCBT, or internet-based cognitive behavioral therapy, is less widely adopted than telehealth, with 41% of all health plans reporting use. Commercial health plans report the most widespread adoption of eCBT, with 96% of plans offering this service. Adoption among public sector payers is considerably lower, with 49% of Medicaid plans using eCBT and 2% of Medicare plans using eCBT.2

Health plans are utilizing consumer portals less frequently than other technology interventions, with 16% of all health plans reporting adoption of consumer portals for their enrollees. Among all plans, Medicaid reported the highest usage of consumer portals at 51%.2

Use of Analytics in Identification and Early Intervention of High-Risk Consumers with Behavioral Conditions

Strategies Focused On Improving Consumer Access To

Care

Strategies For Improving

Consumer Engagement

Improved Coordination Of Care For Consumers

With Behavioral Conditions

Strategies To Ensure Quality Of Behavioral

Health Care

Creating Partnership Models with Behavioral Health Provider Organizations

All Health Plans

n=750

Figure 12 Current Use of Technology-Based Innovations in Improving Consumer Access to Behavioral Health Treatment by Plan Type2

Medicare

n=337

Medicaid

n=141

Commercial

n=246

Telemental Health Services

eCBT and Other eTreatment

Patient Portals

96%

98%

91%

97%

42%

2%

49%

96%

16%

9%

51%

5%

26 | TRENDS IN BEHAVIORAL HEALTH

Successful consumer engagement is a strong predictor of retention and ongoing participation in treatment.12 Engaged consumers take action to become better informed and more proactively involved in decisions and behaviors that affect their health, insurance coverage, and health care.13 Engagement has multiple dimensions, which goes beyond treatment and includes wellness and connection to family, culture, and community.14

Health plans have adopted a wide range of strategies to increase the engagement of consumers with behavioral health disorders. Engagement strategies for consumers can include the use of online tools, recovery management tools, mobile apps, shared decision making initiatives, or guidelines and strategy for staff to better engage consumers and increase shared decision-making. How these different innovations help consumers, varies. For example, mobile apps are particularly helpful to individuals with chronic health care needs providing users medication reminders, refill alerts, and drug interaction warnings.15 Shared decision- making allows consumers to partner in their care and help make informed treatment decisions.13

Adoption of consumer engagement innovations across health plans is low, with no more than 21% of health plans adopting any one innovation. Among payers, Medicaid health plans report the greatest overall current use of innovative engagement strategies – with more than 60% of plans reporting the use of online engagement tools, shared decision-making initiatives, and professional guidelines and strategies for consumers.2

Community-based treatment solutions include networks offering expedited appointments, expanded use of intensive outpatient programs, and expanded use of community-based service delivery, such as assertive community treatment or peer support services.7,10,11 These types of innovations have not been as widely adopted as technology-based solutions. A little over 20% of health plans report the use of community-based service delivery, 17% report expanded use of intensive outpatient programs, and 15% report having networks offering expedited appointments. Adoption of these initiatives is higher in Medicaid than among other payers. For example, 63% of Medicaid plans have adopted expanded use of intensive outpatient programs while 13% of commercial plans and 3% of Medicare plans have adopted this initiative.2

All Health Plansn=750

Figure 13 Current Use of Community-Based Innovations in Improving Consumer Access to Behavioral Health Treatment by Plan Type2

Medicaren=337

Medicaidn=141

Commercialn=246

21%10%

65%13%

Community-based service delivery

(non-office based)

Expanded use of intensive outpatient

programs

Network offering expedited

appointments

HEALTH PLAN CURRENT AND FUTURE USE OF BEHAVIORAL HEALTH CONSUMER ENGAGEMENT STRATEGIES

17%3%

63%13%

15%

53%12%

All Health Plansn=750

Figure 14 Current Use of Behavioral Health Consumer Engagement by Plan Type2

Medicaren=337

Medicaidn=141

Commercialn=246

18%

Recovery self-management

tools for consumers

Shared decision making initiatives

Professional guidelines and

strategiesMobile apps

Online engagement tools

64%

12%

4%

16%

57%

3%

12%

20%

66%

9%

11%

21%

61%

10%

15%

9%

17%

5%

12%

3%

27|

Value-based reimbursement and population health management are built on the premise that payers and provider organizations are focused broadly on the health of consumers. Care coordination has been identified by the Institute of Medicine as one of the key strategies for improving effectiveness and efficiency of the health care system.16 Chronic medical illnesses such as heart disease, cancer, diabetes, and neurological disorders are frequently accompanied by behavioral health disorders. Due to the intertwined nature of these illnesses, coordination of all types of health care is essential.17

Health plans have adopted a wide range of models to improve care coordination for consumers with behavioral health disorders. These models range from specialty care coordination programs, such as a behaviorally-led medical homes; to

HEALTH PLAN CURRENT AND FUTURE USE OF MODELS TO IMPROVE COORDINATION OF CARE FOR CONSUMERS WITH BEHAVIORAL HEALTH CONDITIONS

reimbursement for the colocation of physical and behavioral health services; to pharmacy lock-in programs, which limit what clinical professionals and pharmacies a consumer can visit.18,19

Specialty care coordination programs are the most adopted care coordination innovation across health plans, with 23% of plans reporting use of these types of programs. Least popular among the initiatives is the operation of pharmacy lock-in programs, with only 11% of health plans reporting use. Adoption of care coordination innovations is most popular among Medicaid plans compared to other types of health plans. For example, 88% of Medicaid plans report the use of a specialty care coordination program, compared to 13% of commercial plans, and 5% of Medicare plans.2

All Health Plansn=750

Figure 15 Current Use of Models to Improve Coordination of Care for Consumers with Behavioral Health Conditions by Plan Type2

Medicaren=337

Medicaidn=141

Commercialn=246

11.04%

25.5%

13.1%

Pharmacy lock-in programs

Emergency department diversion programs for behavioral health emergencies

Behavioral health readmission prevention programs

Behavioral health care navigators

Payment models for colocation of services

Specialty care coordination programs

14.92%

6.3%

58.0%

15.77%

55.0%

12.3%

15.27%

57.0%

11.1%

23.18%

5.4%

88.2%

13.1%

16.13%

57.3%

11.9%

4.1%

2.6%

2.9%

2.5%

3.9%

28 | TRENDS IN BEHAVIORAL HEALTH

In addition to implementing programs focused on access, engagement, and coordination, health plans also use innovative strategies to ensure consumers are receiving high quality care. These strategies include reimbursement models built on evidence-based practices, such as intervention for first episode psychosis programs; or certification requirements, such as patient-centered medical home accreditation; or the formation of centers of excellence.20,21,22

Adoption by health plans of quality of care strategies that require certification or additional training were less likely to be

HEALTH PLAN CURRENT AND FUTURE USE OF MODELS TO ENSURE QUALITY OF CARE FOR CONSUMERS WITH BEHAVIORAL HEALTH CONDITIONS

adopted than reimbursement strategies. About 12% of health plans have specialty centers of excellence, 11% have minimum continuing medical education (CME) requirements for behavioral health professionals, and only 9% require patient-centered medical home certification. Adoption of these requirements is much higher in Medicaid than in Medicare and commercial health plans. This may be due to the higher number of consumers with SMI being enrolled in Medicaid, resulting in a greater need for behavioral health interventions.2

All Health Plans n=750

Figure 16 Current Use of Behavioral Health Strategies to Ensure Quality of Care by Plan Type2

Medicare n=337

Medicaid n=141

Commercial n=246

PCMH certification

Minimum CME requirements for BH professionals

Specialty “centers of excellence”

CME = Continuing Medical Education

BH = Behavioral Health

PCMH = Patient-Centered Medical Home

Reimbursement to support evidence-based practices

11%

2%

53%

2%

16%

2%

61%

9%

18%

13%

11%

12%

2%

54%

3%

2%

29|

As part of the move towards greater care coordination, health plans are implementing alternative payment models (APMs) that promote better integrated care management for consumers with co-occurring conditions. APMs move away from traditional fee-for-service (FFS) reimbursement models to reimbursement models that take into account value and/or quality.23,24,25

Currently, the majority of health plans, 93%, have behavioral health provider partner models that utilize a FFS reimbursement structure that also includes a pay-for-performance (P4P) component.2 Typically the P4P component either rewards or penalizes provider organizations for their reporting on quality measures.25 In addition to this P4P model, the use of episodic or bundled payments for specific acute care episodes is gaining traction among certain payers with 42% of plans using this model.2 Bundled payments is an “umbrella term” that includes all types of payments that group consumer costs into a single payment, irrespective of the kinds and quantities of the services provided. This includes global payments and other forms of episodic payments.24,25 Among certain payers, the use of episodic payments varies dramatically. While 95% of commercial health plans use episodic payments, only 2% of Medicare health plans and 47% of Medicaid health plans use these payment arrangements for behavioral health.2

In the future, the likelihood that more health plans will adopt these behavioral health partnership models is thought to be slim. Among the plans that do not already have these types of APMs, only 1.2% of all health plans have plans to adopt episodic payments and 3.5% have plans to adopt FFS reimbursement with a P4P component. No Medicare and commercial health plans have plans to implement episodic payments. Medicaid health plans, on the other hand, may be much more likely to adopt new behavioral health provider partnership models in the future. 6% of Medicaid health plans have future plans to adopt episodic payments and 12% have plans to adopt a FFS reimbursement model with a P4P component.2

HEALTH PLAN CURRENT AND FUTURE USE OF BEHAVIORAL HEALTH PROVIDER PARTNERSHIP MODELS

Episodic/bundled payment for specific

acute episodes

Figure 17 Current Use of Behavioral Health Provider Partnership Models by Model and Plan Type2

Pay-for-performance with fee-for-service

reimbursement systems

Figure 18 Future Use of Behavioral Health Provider Partnership Models by Model and Plan Type2

42.4%

2.3%

47.4%

94.6% 93.2%97.0%

80.8%

95.4%

All Health Plans n=750

Medicare n=337

Medicaid n=141

Commercial n=246

Episodic/bundled payment for specific

acute episodes

Pay-for-performance with fee-for-service

reimbursement systems

All Health Plans n=750

Medicare n=337

Medicaid n=141

Commercial n=246

3.5%

1.3%

12.0%

2.1%1.2%

6.4%

30 | TRENDS IN BEHAVIORAL HEALTH

An estimated 17.9% of adults in the United States have a mental illness (excluding substance use).1 Of these 43 million Americans, about 43% of those surveyed in 2015 received treatment for mental health disorders in the past year.2 The shifting health care market demands different financial and service delivery models with consumer access to high-quality care at the center of this new value equation. Despite this shift, questions remain about both whether consumers actually have adequate access to behavioral health treatment and the quality of that treatment. As the health care system shifts towards a more value-based, coordinated approach to care management and service delivery, maintaining and improving prompt access to high quality services is increasingly important.

Access to care is measured in several ways, including structural measures which facilitate care, such as having health insurance, or a usual source of care; assessments by consumers of how easily they can get health care services; and utilization measures, which include the successful receipt of needed services.3 In considering the factors other than health insurance, the consumer is more likely to trust a clinical professional they are able to see consistently and without delay, and who are able to provide the services the consumer needs.3 With regard to behavioral health, this means evaluating available psychiatrists and psychiatric beds. An analysis of current U.S. licensed psychiatrists and psychiatric beds reveals that while there is not currently a treatment gap for psychiatrists at the national level,4 there is a shortage of psychiatric beds nationally.5 Access to care at the state and local levels varies based on geography and population.

While adequate access to behavioral health professionals and services is crucial, the quality of those services is equally important. Quality of care also has several measures, including those related to structure, such as the number of providers to patients; to process, such as the number of people who received a certain screening; and to outcome, such as rate of adherence or complications.6 While outcome measures may seem to represent a “gold standard” when considering quality, they are the result of numerous other factors,6 including the preceding structural and process factors. Measuring behavioral health quality is still a new development, and selecting key behavioral health quality indicators is complicated.7 The National Committee on Quality Health Assurance (NCQA) Healthcare Effectiveness and Data Information Set (HEDIS) is used by more than 90% of America’s health plans to measure performance,8 and the Centers for Medicare and Medicaid Star Ratings System is the Medicare counterpart for measuring quality and performance.9 While these performance measurement systems have historically focused on physical health care, in recent years there is an emergence of a small number of measures specific to behavioral health quality and consumer access to health care. NCQA analysis of these behavioral health measures has found health plan performance on the measures to be mixed.10 While some behavioral health measures have seen performance gains, others have seen performance declines.11,12,13,14

Positive treatment outcomes in behavioral health are dependent on consumer access to quality care.15 The value evolution in health care will continue to drive the need for improved outcomes, which requires consumers to have access to effective treatment, dedicated care coordination, and high-quality health care professionals.

CONSUMER ACCESS AND QUALITY OF CARE

While the location of treatment service delivery is shifting, consumers require a full behavioral health treatment continuum – with services ranging from acute inpatient services to outpatient and home-based services.16 A proxy indicator for access to a robust treatment continuum is the number and distribution of both licensed psychiatrists and psychiatric beds. Analyses show that while there is not a shortage of psychiatrists at the national level (while geographic distribution is an issue), there is a shortage of psychiatric beds nationally.5

Consumer Access to PsychiatristsThe Health Resources and Services Administration (HRSA) define an adequate number of psychiatrists as one per 30,000 population.17 Analysis of the 2014 HRSA database of licensed psychiatrists, found that at both the national and state level, the U.S. exceeds this criteria. Nationally, there are an estimated 4.3 psychiatrists per 30,000 people. At the state level, Idaho and Wyoming have the fewest number of psychiatrists per 30,000 at 1.7 and 1.9 psychiatrists, respectively. Washington, D.C. and the Commonwealth of Massachusetts have the greatest number of psychiatrists per 30,000 at 17.3 and 10.8 psychiatrists, respectively.4

CONSUMER ACCESS TO BEHAVIORAL HEALTH CARE

CONSUMER ACCESS AND DELIVERY OF CARE

31|

The number of psychiatrists per 30,000 is not the only indicator of access to psychiatric care. In spite of this distribution across the country, there are areas where the behavioral health care needs of children and seniors especially, may not be adequately served by current delivery models and whose behavioral health care demand may not be reflected in current utilization patterns.15 Additionally, insurance coverage and a low income may effect a consumer’s ability to access care.15

Consumer Access to Psychiatric BedsThe industry standard for an adequate number of psychiatric beds was developed by the Treatment Advocacy Center and is defined as 40 to 60 beds per 100,000 people, with a consensus around 50 beds.16 While some states meet this criteria, the U.S. as a whole does not, with 29.8 beds (including acute care hospital designated psychiatric beds, state psychiatric hospital

beds, and private psychiatric beds) per 100,000 people.18 This number does not reflect the distribution of psychiatric hospital beds by state, Medicaid health care financing arrangements, or by bed type. There are 14 states that have at least 40 beds per 100,000 population, and four states that meet the threshold of 50 beds per 100,000 people.18

The type of psychiatric beds—private or state—also affect access to inpatient care. State hospitals are typically seen as a payer of last resort serving the most medically complex patients and those patients that will not be seen by other private provider organizations. Therefore differences in the number of beds per state can effect who receives care.5 For example, while Iowa has 22.6 private psychiatric beds per 100,000 population, the state has only 2.0 public beds per 100,000 population. Comparatively, Nebraska has only 2.4 private beds per 100,000 population, but 15.2 public beds per 100,000 population.18

State Total Psychiatric Beds Per 100,000 People (2016)18

Private Psychiatric Beds Per100,000 People (2016)18

State Psychiatric Beds Per100,000 People (2016)18

Psychiatrists Per30,000 People (2014)4

National 29.8 18.2 11.7 4.3

Alabama 32.7 24.8 7.9 2.5

Alaska 38.5 27.8 10.8 3.6

Arizona 14.8 10.5 4.4 3.2

Arkansas 53.2 45.7 7.4 2.8

California 18.7 3.7 15.0 5.0

Colorado 25.5 15.7 9.8 4.3

Connecticut 39.0 21.8 17.2 9.3

Delaware 46.7 33.9 12.8 3.5

District of Colombia 87.3 45.9 41.4 17.3

Florida 16.2 3.3 12.8 3.0

Georgia 21.8 12.6 9.2 3.0

Hawaii 25.6 11.4 14.1 5.8

Idaho 15.9 5.5 10.3 1.7

Illinois 32.4 21.9 10.5 4.0

Indiana 28.2 15.8 12.3 2.2

Iowa 24.7 22.6 2.0 2.3

Kansas 46.1 30.6 15.5 3.2

Kentucky 39.1 27.8 11.2 3.1

Louisiana 45.9 32.7 13.2 3.6

Figure 19a Psychiatric Beds and Psychiatrists per Population

32 | TRENDS IN BEHAVIORAL HEALTH

State Total Psychiatric Beds Per 100,000 People (2016)18

Private Psychiatric Beds Per100,000 People (2016)18

State Psychiatric Beds Per100,000 People (2016)18

Psychiatrists Per30,000 People (2014)4

Maine 25.7 14.9 10.8 5.3

Maryland 25.9 10.1 15.8 7.2

Massachusetts 29.7 20.7 8.9 10.8

Michigan 28.5 21.7 7.3 3.6

Minnesota 20.0 16.4 3.5 3.7

Mississippi 44.2 27.9 16.3 2.0

Missouri 49.9 35.5 14.3 3.6

Montana 30.9 14.2 16.7 2.7

Nebraska 17.5 2.4 15.1 3.1

Nevada 26.2 16.1 10.1 2.2

New Hampshire 23.3 11.5 11.8 5.4

New Jersey 33.1 15.9 17.2 5.3

New Mexico 23.7 12.7 11.0 4.7

New York 53.5 37.2 16.3 9.2

North Carolina 22.8 14.0 8.8 4.0

North Dakota 32.1 13.6 18.5 3.5

Ohio 29.1 19.4 9.6 3.5

Oklahoma 44.4 33.4 11.0 2.6

Oregon 24.8 8.8 15.9 4.2

Pennsylvania 45.8 35.3 10.4 5.2

Rhode Island 17.6 5.3 12.3 8.6

South Carolina 24.0 14.1 9.9 3.6

South Dakota 25.0 10.2 14.8 2.9

Tennessee 27.4 18.9 8.4 3.1

Texas 27.4 19.4 8.0 2.7

Utah 26.9 18.6 8.3 2.4

Vermont 31.2 27.2 4.0 8.3

Virginia 38.5 20.3 18.1 4.2

Washington 24.1 14.1 10.0 3.4

West Virginia 61.4 47.2 14.2 3.1

Wisconsin 25.2 17.3 7.9 3.4

Wyoming 61.7 27.3 34.3 2.0

Figure 19b Psychiatric Beds and Psychiatrists per Population

33|

Number of Psychiatrists per 30,000 Population4

VT31.2

NH23.3

MA29.7

CT39.0

RI17.6

NJ33.1

DE46.7

MD25.9

DC87.3

WA24.1

MT30.9

ND32.1

SD25.0

NE17.5

KS46.1

OK44.4

TX27.4

NM23.7

CO25.5

WY61.7

UT26.9

AZ14.8

OR24.8

CA18.7

NV26.2

AK38.5

HI25.6

NY53.5

PA45.8

WV61.4

OH29.1

MI28.5

IN28.2

IL32.4

WI25.2

MN20.0

IA24.7

KY39.1

VA38.5

NC22.8

ME25.7

TN27.4

FL16.2

MO49.9

AR53.2

LA45.9

MS44.2

AL32.7

GA21.8

SC24.0

Figure 21 Number of Psychiatric Beds per 100,000 Population18

ID15.9

0.00 to 14.9

15.0 to 24.9

25.0 to 34.9

35.0 to 44.9

45.0 to 54.9

Over 55.0

VT8.3

NH5.4

MA10.8

CT9.3

RI8.6

NJ5.3

DE3.50

MD7.2

DC17.3

WA3.38

MT2.7

ND3.49

SD2.89

NE3.13

KS3.24

OK2.55

TX2.73

NM4.65

CO4.32

WY1.95

UT2.42

AZ3.17

OR4.23

CA4.98

NV2.22

AK3.58

HI5.82

NY9.7

PA5.18

WV3.15

OH3.51

MI3.56

IN2.23

IL3.97

WI3.44

MN3.69

IA2.32

KY3.11

VA4.16

NC4.04

ME5.3

TN3.05

FL2.95

MO3.57

AR2.77

LA3.59

MS2.04

AL2.52

GA3.01

SC3.6

Figure 20

ID1.73

1.00 to 1.99

2.00 t0 2.99

3.00 to 3.99

4.00 to 4.99

Over 5.00

34 | TRENDS IN BEHAVIORAL HEALTH

Consumer access to health care is built on a foundation of quality. As the health care system shifts toward a more value-based, integrated, coordinated approach to care management and service delivery, the quality of consumer health care is increasingly important. A lack of quality behavioral health treatment affects consumer health overall; behavioral health is crucial to overall well being,19 as people with behavioral health disorders are at an increased risk of adverse physical health outcomes.20

Quality of health care in general – and behavioral health in particular — is measured at different levels and through different criteria throughout the delivery system. With approximately 90% of the U.S. population insured, national payer initiatives to measure the quality of care delivered through managed care have the broadest impact.21 Both the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) and The Centers for Medicare and Medicaid Star Ratings performance measurement sets have a small number of process measures specific to behavioral health and consumer access to health care – meaning that they assess an activity or service for a consumer that is carried out by a health care professional, rather than a clinical outcome, as the result of treatment.6 NCQA analysis of these behavioral health measures has found health plan performance on the measures to be mixed.10 While some behavioral health measures have seen performance gains, others have seen performance declines.11,12,13,14

The NCQA HEDIS Quality Measures

The NCQA is a private not-for-profit organization that is widely recognized as providing benchmark data on health care quality in organized systems of care.22 The NCQA HEDIS is used by 90% of health plans to measure performance and for competitive benchmarking.8 HEDIS is comprised of over 80 measures, with 13 measures that specifically address behavioral health.23 NCQA tracks performance gains and declines for each measure year after year using average health plan measure rates for each payer.23 Over the past three to five years,health plan performance on behavioral health measures has varied.11 Of the thirteen behavioral health indicators, six have available trend data. Of these, one measure has seen significant improvement (follow-up care for children prescribed ADHD medication); two measures have seen significant performance declines: follow-up care after hospitalization for mental illness, within seven and thirty days post-discharge; and, initiation and engagement of alcohol and other drug

dependence (AOD) treatment. The remaining measures have not seen either significant performance gains or declines in health plan average scores.11

Medicaid health plans have seen significant performance gains for follow-up care for children ages 6-12 years old prescribed ADHD medication, while commercial health plan performance has remained static on the same measure. The average performance of Medicaid health plans on the number of children receiving follow-up care after the initiation of treatment phase increased 3.4 percentage points between 2011 and 2015 and follow-up care during the continuation of treatment increased 5.0 percentage points. Medicaid and commercial health plan performance on follow-up care for children prescribed ADHD medication was nearly the same between 2011 and 2013; but by 2015, Medicaid health plans were outperforming commercial health plans.12

FOLLOW-UP CARE DURING CONTINUATION OF TREATMENT FOR CHILDREN PRESCRIBED ADHD MEDICATION

Initiation of Alcohol and Other Drug (AOD) treatment has declined for both Medicare and commercial health plans between 2011 and 2015, while Medicaid performance has remained fairly static. Between 2011 and 2015, average commercial health plan performance decreased 6.5 percentage points, while average Medicare health plan performance decreased 10.3 percentage points. Although the average performance by Medicaid health plans was slightly better than Medicare and commercial plans, all had average scores in the 30s.13

Engagement of AOD treatment decreased most dramatically for Medicaid and commercial plans. Between 2011 and 2015, average Medicaid health plan performance decreased 1.7 percentage points and average commercial health plan performance decreased 2.9 percentage points. While Medicare health plans performance decreased the least, at 0.7 percentage points, average Medicare health plan performance was lower than Medicaid and commercial health plans on this measure.13

INITIATION AND ENGAGEMENT OF ALCOHOL AND OTHER DRUG TREATMENT

BEHAVIORAL HEALTH CARE QUALITY

35|

Medicare Medicaid Commercial

First Reporting Year Prior to 2015

Diabetes and Cardiovascular Disease Screening and Monitoring for People With Schizophrenia or Bipolar Disorder24 X

Antidepressant Medication Management24 X X X

Adherence to Antipsychotic Medications for People with Schizophrenia24 X

Initiation and Engagement of Alcohol and Other Drug (AOD) Dependence Treatment24 X X X

Follow-Up Care for Children Prescribed ADHD Medication24 X X

Follow-Up After Hospitalization for Mental Illness- 7 day and 30 day24 X X X

2015 First Reporting Year

Use of Multiple Concurrent Antipsychotics in Children and Adolescents24 X X

Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics24 X X

Metabolic Monitoring for Children and Adolescents on Antipsychotics24 X X

2016 First Reporting Year

Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults24 X X X

2017 First Reporting Year

Follow-Up After Emergency Department Visit for Mental Illness24 X X X

Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence24 X X X

Depression Remission or Response for Adolescents and Adults24 X X X

Figure 22 HEDIS Measures Related to Behavioral Health and Payers Reporting Measures

36 | TRENDS IN BEHAVIORAL HEALTH

Medicaid

Figure 23b Follow-up Care During Continuation of Treatment for Children Prescribed ADHD Medicaid12

45.9 46.450.9

44.6 46.1 46.9

Commercial*

2011 2013 2015

Medicare Medicaid

Figure 24b Engagement of AOD Treatment, Selected Years13

3.8 3.4 3.1

11.910.6 10.2

Commercial*

2011 2013 2015

15.614.3

12.7

Medicaid

Figure 23a Follow-up Care After Initiation of Treatment for Children Prescribed ADHD Medicaid12

39.4 39.1 39.0

Commercial*

2011 2013 2015

Medicare Medicaid

Figure 24a Initiation of AOD Treatment, Selected Years13

Commercial*

2011 2013 2015

38.8 39.642.2

*Commercial performance is represented as the average of HMO and PPO health plan HEDIS scores for years 2011, 2013, and 2015.

44.3

35.8 34.0

39.2 38.2 38.240.4

39.0

33.9

37|

Follow-up within 7 days and 30 days post-discharge after hospitalization for mental illness has decreased significantly for all payer types. Between 2011 and 2015, average Medicare performance for follow-up within seven days post-discharge decreased 4.8 percentage points, Medicaid performance decreased 2.9 percentage points, and commercial performance decreased 6.1 percentage points. Commercial health plans have outperformed Medicaid and Medicare plans on average seven-day follow-up post-discharge in all years. Similar results were found regarding payer performance for follow-up within 30 days post-discharge. For this measure during the same five year period, Medicare performance decreased 5.5 percentage points, Medicaid performance decreased 3.8 percentage points, and commercial performance decreased 4.9 percentage points. Once again, commercial health plans outperformed Medicaid and Medicare plans on average follow-up within 30 days post-discharge in all years.14

The Centers for Medicare and Medicaid Services (CMS) Star ratings measure the effectiveness of Medicare Advantage and Prescription Drug (Part D) plans in terms of quality of care and customer service. Consumers are encouraged to use a health plan’s star rating to aid in selection.25 Medicare uses information from member satisfaction surveys, Medicare Advantage plans, and health care providers (there are 32 measures for medical services and 15 for prescription drugs) to give overall performance star ratings to plans.26 A health plan can get a rating between one and five stars, where five stars is the highest score.25

Of the 32 measures for medical services, only one is specific to behavioral health—”improving or maintaining mental health.”26 This measure is defined as the percent of Medicare members whose mental health is the same or better than expected after two years as self-reported by the member in the Health Outcome Survey.27 Health plan average star ratings have improved consistently on this measure between 2014 and 2016 with the average score rising 1.6 points.26

The CMS Star Ratings also explore several measures related to consumer access and care coordination. These measures are general indicators of health plan effectiveness at supporting consumer access to care and higher quality of care. Performance on these measures have either remained static since 2014 or decreased slightly in quality, but not by a significant amount.26

2014 2015 2016 2017

Improving or 2.0 2.5 3.3 3.6 Maintaining Mental Health

Getting Needed Care 3.6 3.4 3.5 3.3

Getting Appointments 3.5 3.5 3.4 3.3 and Care Quickly

Care Coordination 3.4 3.4 3.4 3.4

FOLLOW-UP POST DISCHARGE

THE CENTERS FOR MEDICARE AND MEDICAID SERVICES QUALITY MEASURES

Medicare Medicaid

Figure 25a Follow-up Within 7 Days Post-Discharge After Hospitalization for Mental Illness14

38.4 34.0 33.6

46.542.0 43.6

Commercial*

2011 2013 2015

56.552.2 50.4

Figure 26 CMS Star Ratings for Medicare Health Plans Relevant to Behavioral Health Access and Quality, 2014-201726

Medicare Medicaid

Figure 25b Follow-up Within 30 Days Post-Discharge After Hospitalization for Mental Illness14

58.4 54.8 52.965.0 60.9 61.2

Commercial*

2011 2013 2015

74.6 70.9 69.7

*Commercial performance is represented as the average of HMO and PPO health plan HEDIS scores for years 2011, 2013, and 2015.

38 | TRENDS IN BEHAVIORAL HEALTH

ADDITIONAL RESOURCES

• America’s Health Insurance Plans (AHIP) is a national advocacy association whose goal it is to improve and protect the health and financial security of consumers, families, businesses, communities, and the nation. (www.ahip.org)

• The Centers for Medicare & Medicaid Innovation (the Innovation Center) supports development and testing of innovative health care payment and service delivery models. (https://innovation.cms.gov/)

• The Kaiser Family Foundation is a non-profit organization focusing on national health issues, as well as the U.S. role in global health policy. (www.kff.org)

• Mental Health America is a community-based nonprofit dedicated to addressing the needs of those living with mental illness and to promoting the overall mental health of all Americans. (http://www.mentalhealthamerica.net/)

• MentalHealth.gov provides one-stop access to U.S. government mental health and mental health problems information. MentalHealth.gov explains the basics of mental health, myths and facts, and more. (https://www.mentalhealth.gov/)

• The National Alliance on Mental Illness (NAMI) is the nation’s largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness. (http://www.nami.org/)

• The National Association of Medicaid Directors (NAMD) is a bipartisan, non-profit, professional organization representing leaders of state Medicaid agencies across the country. (www.medicaiddirectors.org)

• The National Association of State Mental Health Program Directors (NASMHPD) represents the public mental health service delivery system in all 50 states, 4 territories, and the District of Columbia. It is the only association to represent state mental health commissioners/directors and their agencies. (www.nasmhpd.org)

• The National Institute of Mental Health (NIMH) strives to accelerate the pace of scientific progress by generating research that will have the greatest public health impact and continue to fuel the transformation of mental health care. (www.nimh.nih.gov)

• The National Institute on Drug Abuse (NIDA) performs research regarding causes and consequences of drug use and addiction. Its clinical research findings are used to to improve individual and public health. (https://www.drugabuse.gov/)

• OPEN MINDS is a market intelligence and management support firm specializing in the sectors of health and human services serving individuals with complex needs. (www.openminds.com)

• PsychU is comprised of a community of health care professionals dedicated to improving the future of mental health care through information, discussion, and collaboration. (www.psychu.org)

• The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities. (https://www.samhsa.gov/)

• The Veterans Affairs Research and Development program focuses on improving the lives of Veterans and all Americans through health care discovery and innovation. It is part of the Veterans Health Administration, which is the largest integrated health care system in the United States, serving more than 8.9 million Veterans each year. (https://www.research.va.gov/)

39| 39|

1. OPEN MINDS. (2017). OPEN MINDS U.S. Health Care Enrollment By Payer, Proprietary Database.

2. Antonisse, L., Garfield, Rachel, et al. The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review. The Henry J. Kaiser Family Foundation. http://files.kff.org/attachment/Issue‐Brief‐The‐Effects‐of‐Medicaid‐Expansion‐Under‐the‐ACA‐Updated‐Findings. Published February 2017. Accessed March 1, 2017.

3. OPEN MINDS. (2017). OPEN MINDS Managed Care Enrollment, Proprietary Database.

4. Implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA). Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/health‐financing/implementation‐mental‐health‐parity‐addiction‐equity‐act. Updated January 24, 2017. Accessed March 1, 2017.

5. OPEN MINDS. State Medicaid Behavioral Health Carve‐Outs: The OPEN MINDS 2017 Annual Update. OPEN MINDS Market Intelligence Report. https://www.openminds.com/intelligence‐report/state‐medicaid‐bh‐carve‐out‐2017‐update/. Published January 16, 2017. Accessed March 2, 2017.

6. H.R.3590 ‐ Patient Protection and Affordable Care Act. Congress.gov. https://www.congress.gov/bill/111th‐congress/house‐bill/3590. Published March 23, 2010. Accessed March 3. 2017.

7. Medicaid expansion & what it means for you. Healthcare.gov. https://www.healthcare.gov/medicaid‐chip/medicaid‐expansion‐and‐you/. (n.d.) Accessed March 3, 2017.

8. Behind the Term: Serious Mental Illness. SAMHSA’s National Registry of Evidence‐based Programs and Practices. NREPP.SAMHSA.gov. http://www.nrepp.samhsa.gov/Docs/Literatures/Behind_the_Term_Serious%20%20Mental%20Illness.pdf. Published 2016. Accessed March 3, 2017.

9. OPEN MINDS. (2017). OPEN MINDS U.S. Consumers With SMI, Proprietary Database.

10. Dual‐Eligible Beneficiaries of Medicare and Medicaid: Characteristics, Health Care Spending, and Evolving Policies. Congressional Budget Office. https://www.cbo.gov/sites/default/files/113th‐congress‐2013‐2014/reports/44308_DualEligibles2.pdf. Published June 2013. Accessed March 3, 2017.

11. Sparer, Michael. Medicaid managed care: Costs, access, and quality of care. Research Synthesis Report No. 23. Robert Wood Johnson Foundation. http://www.rwjf.org/content/dam/farm/reports/reports/2012/rwjf401106. Published September 2012. Accessed March 7, 2017.

12. Summary of Policies in the Calendar Year (CY) 2017 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site, Facility Fee Payment Amount and Telehealth Services List, and CT Modifier Reduction List. MLN Matters. Centers for Medicare & Medicaid Services. cms.gov. https://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐MLN/MLNMattersArticles/Downloads/MM9844.pdf. Effective January 1, 2017. Accessed March 7, 2017.

NATIONAL BEHAVIORAL HEALTH SYSTEM LANDSCAPE

1. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. samhsa.gov. https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf. Published September 2015. Accessed April 1, 2017.

2. Mental and Substance Use Disorders. samhsa.gov. https://www.samhsa.gov/disorders. Updated March 8, 2016. Accessed April 1, 2017.

3. Mark, T., Yee, T., Levit, K., Camacho-Cook, J., Cutler, E., and Carroll, C. Insurance Financing Increased For Mental Health Conditions But Not For Substance Use Disorders, 1986-2014. Health Affairs 35, no.6 (2016): 958-965 doi:10.1377/hlthaff.2016.002. healthaffairs.org. http://content.healthaffairs.org/content/35/6/958. Published June 2016. Accessed March 1, 2017.

4. Thorpe, K., Jain, S., and Joski, P. Prevalence And Spending Associated With Patients Who Have A Behavioral Health Disorder And Other Conditions. Health Affairs 36, no.1 (2017): 124-132 doi: 10.1377/hlthaff.2016.0875. healthaffairs.org. http://content.healthaffairs.org/content/36/1/124. Published January 2017. Accessed March 3, 2017.

FOREWORD

SOURCES

40 | TRENDS IN BEHAVIORAL HEALTH

13. Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year (CY) 2017. Centers for Medicare & Medicaid Services. cms.gov. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact‐sheets/2016‐Fact‐sheets‐items/2016‐07‐07‐2.html. Published July 7, 2016. Accessed March 7, 2017.

14. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Bid Pricing Data Release; Medicare Advantage and Part D Medical Loss Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model; Medicare Shared Savings Program Requirements. Centers for Medicare & Medicaid Services. 2016;81(220), 80170‐80556. https://www.federalregister.gov/documents/2016/11/15/2016‐26668/medicare‐program‐revisions‐to‐paymentpolicies‐under‐the‐physician‐fee‐schedule‐and‐other‐revisions. Published November 15, 2016. Accessed March 7, 2017.

15. Better Care. Smarter Spending. Healthier People: Paying Providers for Value, Not Volume. Centers for Medicare & Medicaid Services. cms.gov. https://www.cms.gov/newsroom/mediareleasedatabase/fact‐sheets/2015‐fact‐sheets‐items/2015‐01‐26‐3.html. Published January 26, 2015. Accessed March 8, 2017.

16. Quality Payment Program. Centers for Medicare & Medicaid Services. cms.gov. https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐ Instruments/Value‐Based‐Programs/MACRA‐MIPS‐and‐APMs/MACRA‐Quality‐Payment‐Program‐webinar‐slides‐10‐26‐16.pdf (n.d.) Accessed March 8, 2017.

17. Medicare Program; Merit‐ Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician‐Focused Payment Models. Centers for Medicare & Medicaid Services. 2016;81(214), 77008‐77831. https://www.federalregister.gov/documents/2016/11/04/2016‐25240/medicare‐program‐merit‐based‐incentive‐payment‐system‐mips‐and‐alternative‐paymentmodel‐apm. Published November 14, 2016. Accessed March 8, 2017.

18. Mann, Cindy. RE: Policy Considerations for Integrated Care Models. Center for Medicaid and CHIP Services. Medicaid.gov. https://www.medicaid.gov/federal‐policyguidance/downloads/smd‐12‐002.pdf. Published July 10, 2012. Accessed March 8, 2017.

19. MO 11‐11 Approval Letter. Centers for Medicaid & Medicare Services. Medicaid.gov. https://www.medicaid.gov/state‐resource‐center/medicaid‐state‐technicalassistance/ health‐homes‐technical‐assistance/downloads/missouri‐spa‐11‐11.pdf. Published October 20, 2011. Accessed March 8, 2017.

20. Missouri CMHC Healthcare Homes: Progress Update. Dmh.mo.gov. Missouri Department of Mental Health. https://dmh.mo.gov/mentalillness/docs/outcomes16.pdf. (n.d.) Accessed March 8, 2017.

21. Medicaid & Children’s Health Insurance Programs (CHIP); Medicaid Managed Care, CHIP Delivered in Managed Care, & Revisions Related to Third Party Liability. Centers for Medicare & Medicaid Services. 2016;81(88), 27498‐27901. https://www.federalregister.gov/documents/2016/05/06/2016‐09581/medicaid‐and‐childrenshealth‐ insurance‐program‐chip‐programs‐medicaid‐managed‐care‐chip‐delivered. Published May 6, 2016. Accessed March 8, 2017.

22. The Mental Health & Substance Use Disorder Parity Task Force: Final Report. United States Health And Human Service Department. Hhs.gov. https://www.hhs.gov/sites/default/files/mental‐health‐substance‐use‐disorder‐parity‐task‐force‐final‐report.PDF. Published October 2016. Accessed March 9, 2017.

23. Coughlin, Teresa A., Holahan, John, Caswell, Kyle, McGrath, Megan. Uncompensated Care for Uninsured in 2013: A Detailed Examination. https://kaiserfamilyfoundation.files.wordpress.com/2014/05/8596‐uncompensated‐care‐for‐the‐uninsured‐in‐2013.pdf. Published May 2014. Accessed March 10, 2017.

24. Report to Congress on Medicaid Disproportionate Share Hospital Payments. Medicaid and CHIP Payment and Access Commission. Macpac.gov. https://www.macpac.gov/wp‐content/uploads/2016/01/Report‐to‐Congress‐on‐Medicaid‐DSH.pdf. Published February 2016. Accessed March 10, 2017.

25. Criteria for the Demonstration Program to Improve Community Mental Health Centers and to Establish Certified Community Behavioral Health Clinics. Substance Abuse and Mental Health Services Administration. Samhsa.gov. https://www.samhsa.gov/sites/default/files/programs_campaigns/ccbhc‐criteria.pdf. (n.d.) Accessed March 10, 2017.

26. Section 223 Demonstration Program for Certified Community Behavioral Health Clinics. Substance Abuse and Mental Health Services Administration. Samhsa.gov. https://www.samhsa.gov/section‐223. Updated March 31, 2017. Accessed March 10, 2017.

27. Planning Grants for Certified Behavioral Health Clinics. Substance Abuse and Mental Health Services Administration. Samhsa.gov.

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28. Jost, T. House Passes AHCA: How It Happened, What It Would Do, And Its Uncertain Senate Future. Health Affairs Blog. Healthaffairs.org http://healthaffairs.org/blog/2017/05/04/house-passes-ahca-how-it-happened-what-it-would-do-and-its-uncertain-senate-future/. Published May 4, 2017. Accessed May 19, 2017.

29. Patient Protection and Affordable Care Act; Market Stabilization. Federal Register: Proposed Rules. Centers for Medicare & Medicaid Services. 82(32), 10980‐10998. https://11042‐presscdn‐0‐63‐pagely.netdna‐ssl.com/wp‐content/uploads/indres/021717nprmacamarketstabilize.pdf. Published February 17, 2017. Accessed March 11, 2017.

30. Price, Thomas E., Verma, Seema. The Secretary of Health and Human Services. hhs.gov. https://www.hhs.gov/sites/default/files/sec‐price‐admin‐verma‐ltr.pdf. (n.d.) Accessed March 11, 2017.

31. Unique Veteran Users Profile FY 2015. National Center for Veterans Analysis and Statistics. Va.gov. https://www.va.gov/vetdata/docs/SpecialReports/Profile_of_Unique_Veteran_Users_2015.pdf. Published December 2016. Accessed March 12, 2017.

32. West Alan N., Charlton Mary E., Vaughan‐SarrazinMary. Dual use of VA and non‐VA hospitals by Veterans with multiple hospitalizations. BMC Health Services Research. 2015;15:431. doi:10.1186/s12913‐015‐1069‐8. Published September 29, 2015. Accessed March 12, 2017.

33. Comparing the Costs of the Veterans Health Care System with Private‐Sector Costs. United States Congressional Budget Office. https://11042‐presscdn‐0‐63‐ pagely.netdna‐ssl.com/wp‐content/uploads/indres/CBO‐VA‐Health‐Care‐Cost‐Comparison.pdf. Published December 2014. Accessed March 12, 2017.

34. VA Mental Health: Clearer Guidance on Access Policies and Wait‐Time Data Needed. (2015, October). United States Government Accountability Office. http://www.gao.gov/assets/680/673396.pdf. Published October 2015. Accessed March 12, 2017.

35. VA Mental Health Care. Fact Sheet. U.S. Department of Veterans Affairs. Va.gov. https://www.va.gov/opa/publications/factsheets/April‐2016‐Mental‐Health‐Fact‐Sheet.pdf. Published April 2016. Accessed March 12, 2017.

36. Community Based Outpatient Clinic Cyclical Reports. U. S. Department of Veterans Affairs Office of Inspector General. va.gov. https://www.va.gov/oig/54/reports/vaoig‐08‐00623‐169.pdf. Published July 16, 2009. Accessed March 12, 2017.

37. Volume II Medical Programs and Information Technology Programs Congressional Submission FY 2017 Funding and FY 2018 Advance Appropriations. Department of Veterans Affairs. va.gov. https://www.va.gov/budget/docs/summary/Fy2017‐VolumeII‐MedicalProgramsAndInformationTechnology.pdf. (2017). Accessed March 13, 2017.

38. OPEN MINDS. (2017). Veterans Mental Health Care, Proprietary Database

39. Review of Veterans’ Access to Mental Health Care. Veterans Health Administration. VA Office of Inspector General. va.gov. https://www.va.gov/oig/pubs/VAOIG‐12‐ 00900‐168.pdf. Published April 23, 2012. Accessed March 13, 2017.

40. Pending Appointment and Electronic Wait List Summary. Veterans Administration. va.gov. https://www.va.gov/HEALTH/docs/DR65_032017_Pending_and_EWL_Biweekly_Desired_Date_Division.pdf. Updated March 1, 2017. Accessed March 14, 2017.

41. Audit of VHA’s Efforts To Improve Veterans’ Access to Outpatient Psychiatrists. Veterans Administration. https://www.va.gov/oig/pubs/VAOIG‐13‐03917‐487.pdf. Published August 25, 2015. Accessed March 14, 2017.

42. VHA Workforce and Succession Strategic Plan 2016. Veterans Health Administration. vacareers.va.gov. https://www.vacareers.va.gov/assets/common/print/2016‐vhaworkforce‐succession‐strategic‐plan.pdf. Published 2016. Accessed March 14, 2017.

43. Veterans Access, Choice and Accountability Act of 2014: Fact Sheet. U.S. Department of Veterans Affairs. va.gov. https://www.va.gov/opa/choiceact/documents/choice‐act‐summary.pdf. (n.d.). Accessed March 14, 2017.

44. Locations. U.S. Department of Veterans Affairs. va.gov. https://www.va.gov/directory/guide/map.asp?dnum=1. Published 2015. Accessed March 14, 2017.

45. OPEN MINDS. (2017). OPEN MINDS Veterans Integrated Service Network, Proprietary Database.

42 | TRENDS IN BEHAVIORAL HEALTH

1. Substance Abuse and Mental Health Services Administration. Behavioral Health Spending and Use Accounts, 1986–2014. HHS Publication No. SMA‐16‐4975. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2016. http://store.samhsa.gov/shin/content/SMA16‐4975/SMA16‐4975.pdf. Published 2016. Date Accessed March 1, 2017.

2. OPEN MINDS. (2017). OPEN MINDS U.S. Consumers With SMI, Proprietary Database.

3. OPEN MINDS. (2016‐2017). OPEN MINDS Medicaid Behavioral Health Financing Arrangements Proprietary Database.

4. OPEN MINDS. (2017). OPEN MINDS SMI Population Primary Financing System, Proprietary Database.

5. OPEN MINDS (2016‐2017). OPEN MINDS Patient Centered Medical Homes Proprietary Database.

6. Medicaid.gov. Approved Medicaid Health Home State Plan Amendments. https://www.medicaid.gov/state-resource-center/medicaid-state-technicalassistance/health-homes-technical-assistance/downloads/hh-map.pdf. Updated November 2016. Accessed March 1, 2017.

7. Cms.gov. Financial Alignment Initiative. Capitated Model. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/CapitatedModel.html. Updated November 23, 2016. Accessed March 3, 2017.

8. Cms.gov. Financial Alignment Initiative. Managed Fee for Service Model. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid- Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/ManagedFeeforServiceModel.html. Updated August 24, 2016. Accessed March 3, 2017.

9. Chcs.org. Medicaid Accountable Care Organizations: State Update. Fact Sheet. Center for Health Care Strategies, Inc. http://www.chcs.org/media/ACOFact‐Sheet‐01‐30‐17.pdf. Published January 2017. Accessed March 5, 2017.

10. Medicaid.gov. State Plan Amendments Re: CT SPA 17-0002. https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/CT/CT-17-0002.pdf. Effective Date January 1, 2017. Access Date March 5, 2017.

11. HHS.gov. HHS selects eight states for new demonstration program to improve access to high quality behavioral health services. http://wayback.archiveit.org/3926/20170128161256/https://www.hhs.gov/about/news/2016/12/21/hhs-selects-eight-states-new-demonstration-program-improve-access-highquality- behavioral-health. Updated Date December 21, 2016. Access Date March 6, 2017.

12. Medicaid.gov. Eligibility. https://www.medicaid.gov/medicaid/eligibility/. Access Date March 6, 2017.

13. Medicaid.gov. List of Medicaid Eligibility Groups. https://www.medicaid.gov/medicaid‐chip‐program‐information/by‐topics/waivers/1115/downloads/list‐ofeligibility‐groups.pdf. Accessed March 6, 2017.

14. Office of the Assistant Secretary for Planning and Evaluation. (2017, January 18). MEDICAID EXPANSION IMPACTS ON INSURANCE COVERAGE AND ACCESS TO CARE. https://aspe.hhs.gov/system/files/pdf/255516/medicaidexpansion.pdf. Updated January 18, 2017. Accessed March 6, 2017.

15. OPEN MINDS. (2017, January 16). State Medicaid Behavioral Health Carve‐Outs: The OPEN MINDS 2017 Annual Update. OPEN MINDS Market Intelligence Report. https://www.openminds.com/intelligence‐report/state‐medicaid‐bh‐carve‐out‐2017‐update/

16. OPEN MINDS. (2015). OPEN MINDS State U.S. Health Care Coverage Proprietary Database.

17. OPEN MINDS (2017). OPEN MINDS Mental Health Pharma Benefits Proprietary database

18. The Changing Medicaid Carve‐Out Market: The 2016 Update On Vertical Carve‐Outs. OPEN MINDS Market Intelligence Report. https://www.openminds.com/downloads/changing‐medicaid‐carve‐market‐2016‐open‐minds‐update‐vertical‐carve‐outs/. Published August 2016. Accessed March 7, 2017.

19. Specialty Plan. Magellan Complete Care of Florida. https://www.magellancompletecareoffl.com/fl‐site/specialty‐plan/welcome.aspx. Date Accessed March 7, 2017.

20. Social Security Administration. Annual Statistical Report On The Social Security Disability Insurance Program, 2015. https://www.ssa.gov/policy/docs/statcomps/di_asr/2015/di_asr15.pdf. Published October 2016. Accessed March 7, 2017.

STATE BEHAVIORAL HEALTH FINANCING AND SERVICE DELIVERY SYSTEMS

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1. Berwick, D, Nolan, T, Whittington, J. The Triple Aim: Care, Health, And Cost. Health Affairs 27. no. 3 (2008): 759‐769 doi: 10.1377/hlthaff.27.3.759. healthaffairs.org. http://content.healthaffairs.org/content/27/3/759.full. Published 2008. Accessed March 1, 2017.

2. OPEN MINDS. (2017). OPEN MINDS Health Plan Proprietary Database.

3. The High Concentration of U.S. Health Care Expenditures: Research in Action. Issue 19. Agency for Healthcare Research and Quality, Rockville, MD. Ahrq.gov. http://archive.ahrq.gov/research/findings/factsheets/costs/expriach/index.html. Published June 2006. Accessed March 1, 2017.

4. Conrad, D. Implementing Value‐Based Payment Reform: Learning From The Field Of Practice. Health Affairs Blog. Healtaffairs.org. http://healthaffairs.org/blog/2015/04/14/implementing‐value‐based‐payment‐reform‐learning‐from‐the‐field‐of‐practice/. Published April 14, 2015. Accessed March 1, 2017.

5. ‘How to’ Guide: The BCF Technical Toolkit. Section 1: Population Segmentation, Risk Stratification and Information Governance. NHS England. https://www.england.nhs.uk/wp‐content/uploads/2014/09/1‐seg‐strat.pdf. Published August 2014. Accessed March 1, 2017.

6. Access to Health Services. Healthy People 2020. healthypeople.gov. https://www.healthypeople.gov/2020/topics‐objectives/topic/Access‐to‐Health‐Services. (n.d). Accessed March 2, 2017.

7. Gingrass, J. Breaking down barriers: Rethinking patient access strategies. http://www.ecgmc.com/thought‐leadership/blog/breaking‐down‐barriers‐rethinkingpatient‐access‐strategies. Published December 3, 2014. Accessed March 2, 2017.

8. Cartreine, J. Online cognitive behavioral therapy: The latest trend in mental health care. Harvard Health Publications. http://www.health.harvard.edu/blog/online‐cognitive‐behavioral‐therapy‐the‐latest‐trend‐in‐mental‐health‐care‐201511048551. Published November 4, 2015. Accessed March 3, 2017

9. Hilty, D., Ferrer, D., Parish, M., Johnston, B., Callahan, E., Yellowlees, P. The Effectiveness of Telemental Health: A 2013 Review. Telemed J E Health. 2013 Jun; 19(6): 444‐454. doi: 10.1089/tmj.2013.0075. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662387/. Published June 2013. Accessed March 3, 2017.

10. Appold, K. Five things to know: How one health system offers same‐day specialty appointments. Managed Healthcare Executive. http://managedhealthcareexecutive.modernmedicine.com/managed‐healthcare‐executive/news/five‐things‐know‐how‐one‐health‐system‐offers‐same‐dayspecialty‐appointments. Published February 16, 2017. Accessed March 3, 2017.

11. Sanders, M. STRATEGIES FOR ENGAGING DIFFICULT‐TO‐REACH, MULTI‐ PROBLEM CLIENTS WITH SUBSTANCE USE DISORDERS. http://www.onthemarkconsulting25.com/Documents/STRATEGIES%20FOR%20ENGAGING%20DIFFICULT.pdf. (n.d.) Accessed March 5, 2017.

HEALTH PLAN POPULATION HEALTH MANAGEMENT

21. U.S. Department of Health & Human Services. Defining the PCMH. https://pcmh.ahrq.gov/page/defining-pcmh. (n.d.). Accessed March 8, 2017.

22. Guide to Medicaid Health Home Design and Implementation. Medicaid.gov. https://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/healthhomes- technical-assistance/guide-to-health-homes-design-and-implementation.html. (n.d.). Accessed March 3, 2017.

23. Center for Health Care Strategies, Inc. Core Considerations for Implementing Medicaid Accountable Care Organizations. http://www.chcs.org/media/CoreConsiderationsforMedicaidACO__Final.pdf. Published November 2012. Accessed March 8, 2017.

24. Chepaitis, A., Greene, A. M., Hoover, S., Khatutsky, G., Lyda‐McDonald, B., Ormond, C., et al. Report on Early Implementation of Demonstrations under the Financial Alignment Initiative. Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare‐Medicaid‐Coordination/Medicare‐and‐Medicaid‐Coordination/Medicare‐Medicaid‐Coordination‐Office/FinancialAlignmentInitiative/Downloads/MultistateIssueBriefFAI.pdf. Published October 15, 2015. Accessed March 8, 2017.

25. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Planning Grants for Certified Community Behavioral Health Clinics. https://www.samhsa.gov/sites/default/files/grants/pdf/sm-16-001.pdf#page=94. (n.d.). Accessed March 9, 2017.

44 | TRENDS IN BEHAVIORAL HEALTH

1. Any Mental Illness (AMI) Among U.S. Adults, (n.d.). National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-ami-among-us-adults.shtml

CONSUMER ACCESS AND DELIVERY OF CARE

12. Block, P. Consumer Access, Customer Service & Consumer Engagement Functionality In Population Health Management: Preparing For Value‐Based Reimbursement. OPEN MINDS Performance Management Institute. https://www.openminds.com/market‐intelligence/resources/consumer‐access‐customerservice‐functionality‐in‐population‐health‐management‐preparing‐for‐value‐based‐reimbursement/. Published February 17, 2017. Accessed March 5, 2017.

13. Oss, M. Making Consumer Engagement A Reality. OPEN MINDS. Openminds.com. https://www.openminds.com/market‐intelligence/executivebriefings/making‐consumer‐engagement‐reality/. Published April 11, 2017. Accessed April 15, 2017.

14. Person and Family Engagement Strategy. Centers For Medicare & Medicaid Services. https://11042‐presscdn‐0‐63‐pagely.netdna‐ssl.com/wpcontent/uploads/indres/121216medicarestratpfe.pdf. Published November 22, 2016. Accessed March 6, 2017

15. Landi, H. Study Finds Only a Minority of Mobile Health Apps Useful for Patient Engagement. Healthcare Informatics. https://www.healthcareinformatics. com/news‐item/study‐finds‐only‐minority‐mobile‐health‐apps‐useful‐patient‐engagement. Published February 19, 2016. Accessed March 6, 2017.

16. DuVernay‐Bielaszka, C. Health Policy Brief: Improving Quality and Safety. Health Affairs. http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_45.pdf. Published April 15, 2011. Accessed March 7, 2017.

17. Innovative Medicaid Managed Care Coordination Programs for Co‐Morbid Behavioral Health and Chronic Physical Health Conditions: Final Report. Office Of The Assistant Secretary For Planning And Evaluation. https://aspe.hhs.gov/basic‐report/innovative‐medicaid‐managed‐care‐coordinationprograms‐co‐morbid‐behavioral‐health‐and‐chronic‐physical‐health‐conditions‐final‐report#strategy. Published May 1, 2015. Accessed March 7, 2017.

18. Nardone, M., Snyder, S., Paradise, J. Integrating Physical and Behavioral Health Care: Promising Medicaid Models. Kff.org. http://kff.org/reportsection/integrating‐physical‐and‐behavioral‐health‐care‐promising‐medicaid‐models‐issue‐brief/. Published February 12, 2014. Accessed March 7, 2017.

19. Bayer, E. Strategies to Reduce Prescription Drug Abuse: Lessons Learned from the ACAP SUD Collaborative. ACAP. http://www.communityplans.net/Portals/0/Fact%20Sheets/ACAP_Substance_Use_Disorder_Toolkit.pdf. Published April 2015. Accessed March 7, 2017.

20. Heinssen, R., Goldstein, A., Azrin, S. Evidence‐Based Treatments for First Episode Psychosis: Components of Coordinated Specialty Care. https://www.nimh.nih.gov/health/topics/schizophrenia/raise/nimh‐white‐paper‐csc‐for‐fep_147096.pdf. Published April 14, 2014. Accessed March 8, 2017.

21. Milburn, J., Maurar, M., Strategies for Value‐Based Physician Compensation. http://www.mgma.com/Libraries/Assets/Store/Books/8652‐excerpt.pdf. Published 2013. Accessed March 8, 2017.

22. Rodak, S. Is Center of Excellence Investment the Silver Bullet Healthcare Has Been Looking For? Becker’s Hospital Review. http://www.beckershospitalreview.com/hospital‐key‐specialties/is‐center‐of‐excellence‐investment‐the‐silver‐bullet‐healthcare‐has‐been‐lookingfor.html. Published March 4, 2013. Accessed February 9, 2017.

23. The Role of State Medicaid Programs in Improving the Value of the Health Care System. National Association of Medicaid Directors. http://medicaiddirectors.org/wp‐content/uploads/2016/03/NAMD_Bailit‐Health_Value‐Based‐Purchasing‐in‐Medicaid.pdf. Published March 22, 2016. Accessed February 9, 2017.

24. America’s Essential Hospitals. Policy Briefs. The Landscape of Medicaid Alternative Payment Models. https://essentialhospitals.org/policy/thelandscape‐of‐medicaid‐alternative‐payment‐models/. Published September 2014. Accessed February 10, 2017.

25. News.aetna.com. Value‐based care: better care, better health, lower costs. https://news.aetna.com/2015/01/value‐based‐care‐better‐care‐betterhealth‐lower‐costs/. (n.d.). Accessed February 10, 2017.

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2. Park-Lee, E., Lipari, R. N., Hedden, S. L., Copello, E. A., & Kroutil, L. A.. Receipt of Services for Substance Use and Mental Health Issues among Adults: Results from the 2015 National Survey on Drug Use and Health, (2016, September). NSDUH Data Review, SAMSHA. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-ServiceUseAdult-2015/NSDUH-ServiceUseAdult-2015/NSDUH-ServiceUseAdult-2015.htm

3. Chapter 9. Access to Health Care. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhqr11/chap9.html

4. OPEN MINDS. (2017). OPEN MINDS U.S. Psychiatrists Proprietary Database.

5. Fuller, D.A., Sinclair, E., Geller, J., Quanbeck, C., Snook, J. (2016). Going, going, gone: Trends and consequences of eliminating state psychiatric beds. 2016, Arlington, VA: Treatment Advocacy Center. Retrieved from http://www.treatmentadvocacycenter.org/storage/documents/going-going-gone.pdf

6. Types of Quality Measures. (2011, July). Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from http://www.ahrq.gov/professionals/quality-patient-safety/talkingquality/create/types.html

7. National Behavioral Health Quality Framework – Overview. (2014, October 30). Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/national-behavioral-health-quality-framework

8. HEDIS & Performance Measurement. (2017). NCQA. Retrieved from http://www.ncqa.org/hedis-quality-measurement

9. Star Ratings (2017). Centers For Medicare & Medicaid Services. Retrieved from https://www.medicare.gov/find-aplan/staticpages/rating/planrating-help.aspx

10. The State of Health Care Quality 2015, (2015). NCQA. Retrieved from http://blog.ncqa.org/wp-content/uploads/SOHC-2015-Slides.pdf

11. Significant Performance Gains/Declines, (n.d.). NCQA. Retrieved from http://www.ncqa.org/report-cards/health-plans/state-of-health-carequality/2016-table-of-contents/significant-performance-gains-declines

12. Follow-Up Care for Children Prescribed ADHD Medication, (2016). NCQA.org. http://www.ncqa.org/report-cards/health-plans/state-ofhealth-care-quality/2016-table-of-contents/adhd. Published 2016. Accessed March 3, 2017. A. The Commercial numbers are an average of the Commercial HMO and PPO numbers.

13. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment. (2016). NCQA.org. http://www.ncqa.org/report-cards/healthplans/state-of-health-care-quality/2016-table-of-contents/alcohol-treatment. Published 2016. Accessed March 3, 2017. A. The Commercial and Medicare numbers are an average of the Commercial and Medicare HMO and PPO numbers.

14. Follow-Up After Hospitalization for Mental Illness, (2016). NCQA.org. Retrieved from http://www.ncqa.org/report-cards/health-plans/stateof-health-care-quality/2016-table-of-contents/follow-up. Published 2016. Accessed March 3, 2016. A. The Commercial and Medicare numbers are an average of the Commercial and Medicare HMO and PPO numbers.

15. NREPP Learning Center Literature Review: Mental Health Disparities, Prepared in 2016 by Development Services Group, Inc., re: no. 283-12-3702. Retrieved from http://nrepp.samhsa.gov/Docs/Literatures/NREPP%20Learning%20Center%20Literature%20Review_Mental%20Health%20Disparities.pdf

16. Psychiatric Bed Supply Need Per Capita, (2016, September). Treatment Advocacy Center. Retrieved from http://www.treatmentadvocacycenter.org/storage/documents/backgrounders/bed‐supply‐need‐per‐capita.pdf

17. Criteria for Designating of Areas Having Shortages of Mental Health Professionals, 42 CFR Appendix C to Part 5, Cornell University School of Law. Retrieved from https://www.law.cornell.edu/cfr/text/42/appendix‐C_to_part_5

18. OPEN MINDS. (2017). OPEN MINDS United States Psychiatric Bed Proprietary Database.

19. Investing in Mental Health. (2003) Department of Mental Health and Substance Dependence, Noncommunicable Diseases and Mental Health, World Health Organization, Geneva. Retrieved from http://www.who.int/mental_health/media/investing_mnh.pdf

20. Carter, R., McClellan, C., Woodward, A. Adults In Poor Physical Health Reporting Behavioral Health Conditions Have Higher Health Costs. Samhsa.gov. https://www.samhsa.gov/data/sites/default/files/report_2107/ShortReport-2107.html. Published April 26, 2016. Accessed May 2, 2017.

21. Health Insurance Coverage of the Total Population. (2015) Kaiser Family Foundation. Retrieved from http://kff.org/other/state-indicator/totalpopulation/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

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22. About NCQA. (n.d.). NCQA. Retrieved from http://www.ncqa.org/AboutNCQA.aspx

23. HEDIS Measures. (2016). NCQA. Retrieved from http://www.ncqa.org/hedis-quality-measurement/hedis-measures

24. Summary Table of Measures, Product Lines and Changes, NCQA. (2016). HEDIS 2016. NCQA. Retrieved from https://www.ncqa.org/Portals/0/HEDISQM/HEDIS2017/HEDIS%202017%20Volume%202%20List%20of%20Measures.pdf?ver=2016-06-27-135433-350

25. The five-star rating system and Medicare plan enrollment. (n.d.). Powered by the Medicare Rights Center. Retrieved from https://www.medicareinteractive.org/get-answers/overview-of-medicare-health-coverage-options/changingmedicare-health-coverage/the-five-star-rating-system-and-medicare-plan-enrollment

26. Fact Sheet - 2017 Star Ratings. (2017). Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2017-Part-C-and-D-Medicare-Star-Ratings-Data-v11-02-2016-.zip

27. Medicare 2017 Part C & D Star Rating Technical Notes. (2016, September 16). Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2017-Part-C-and-D-Medicare-Star-Ratings-Data-v11-02-2016-.zip

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