Why Medicaid exclusion for behavioral health in Pennsylvania could be a model of integrated care nationwide

Medicaid’s localized approach in Pennsylvania could be a model for integrating behavioral and physical health nationwide.

That’s according to the University of Pittsburgh Medical Center (UPMC) health plan and community care behavioral health organization, which recently published a policy report in the Journal of Psychiatric Services.

Unlike other states, Medicaid behavioral health in Pennsylvania is funded and managed by counties that contract with behavioral health managed care organizations. These counties also run social support programs, such as housing services.

Behavioral Health is an exclusive benefit in Pennsylvania. Yet it was conceptualized from the outset as a model of integrated human services, according to Dr. Matthew Hurford, president of Community Care Behavioral Health Organization and vice president of behavioral health for UPMC Insurance Services.

“There was an early recognition that people with serious mental illnesses and substance use disorders … are often overrepresented in social service systems like housing, criminal justice, child protection childhood,” Hurford told Behavioral Health Business. “Since many of these services are run at the county level in Pennsylvania, it made sense that Medicaid funding for behavioral health would also be run at the county level. [That’s] to enable policy alignment and blended finance to strengthen these systems and help streamline the complexity facing…people with behavioral health issues.

UPMC Insurance Services is owned and operated by the University of Pittsburgh Medical Center. It covers 4.5 million members and provides commercial products for groups and individuals.

He owns the managed behavioral health care nonprofit Community Care Behavioral Health Organization, which was founded in 1996 to support Pennsylvania’s HealthChoices program for Medicaid recipients.

Hurford noted that behavioral health exclusions are often viewed as a barrier or limitation to integrating behavioral health care.

“What we were able to demonstrate in Pennsylvania is really the opposite,” Hurford said.

There are several reasons for this, he explained.

“So many areas of someone’s life, what we now think of as social determinants of health and health-related social needs, are met by these county-level systems,” Hurford said. “It’s a lot easier to integrate and integrate physical health care than it is to try to start with health care and go out and partner with all these other systems of organizations that meet those needs. in social and human services.

The model has had some recent successes. The policy report found that overall medical costs for community care members have fallen by 15% due to a reduction in hospital services over the past two years.

Hurford noted that holistic services that help address the social determinants of health contribute to these reductions.

“In Pennsylvania, we require the Medicaid program to include community organizations in our value-based payment agreements, which we don’t see as a onerous mandate but a golden opportunity,” Hurford said. “Because we know that things like helping people recover in their communities and not being readmitted to hospital … will be impossible if they are not housed in a stable way or if they do not have access to food.”

There has also been a massive increase in the number of Community Care Medicaid members using drug treatment (MAT). The number of members receiving MAT jumped 43% from January 2018 to June 2022.

Hurford attributes part of the success of the MAT program to a grant the UMPC received in conjunction with Pennsylvania Department of Drug and Alcohol programs.

“We have implemented a star model for drug therapy,” he said. “This model includes a Super Hub, located at UPMC Western Psychiatric Hospital, and then an array of regional hubs, at the level of Single County Authorities (SCAs), local drug and alcohol authorities of the county, in a number of rural counties. The team has worked with a network of providers, not just medication-assisted treatment, but also some of the social service agencies that we’ve talked about that help meet those needs. »

While localizing Medicaid behavioral health allows counties to practice holistic care, collaboration is key to success.

“You just can’t do this job alone, and we have to approach this with a degree of organizational humility,” he said. “As health care providers, we do pretty well if we can impact 10-15% of a person’s total health. The other 85% to 90% is a function of so many other things, where people live, what kind of meaning they have in their lives, etc.

Hurford said the county-level model could be replicated in other areas.

“The Pennsylvania model provides this unique platform where, because Medicaid funding is managed at the county level, you have communities that know their [populations] better than anyone,” Hurford said. “It provides that platform to engage with payers, providers, members, their families, community organizations, to bring them together in an integrated and holistic way to address the challenges of people in the full context of their lives, and not just based on their diagnosis or condition. ”

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