The case studies related to improving behavioral health business practices (Appendix B) focused on how SMHAs and SSAs are promoting and supporting changes to provider business practices as the provision of health care services evolves, especially with implementation of the
Affordable Care Act. Changing business practices include system reorganization, adoption of information technology, determining quality assurance, and adapting billing practices.
1. State Activities
The Truven Health team interviewed five states on this topic: Arizona, Kentucky, Maryland, Oklahoma, and Washington. The focus for Washington is on their creation of an integrated analytic database that links data from health claims files with outcomes data from a wide variety of outcomes related to health, criminal justice, employment, and social welfare.
1.1 Expending Medicaid Eligibility
Four of the five states interviewed for this section expanded Medicaid eligibility as authorized under the Affordable Care Act; only Oklahoma was not expanding Medicaid at the time of this study. Medicaid expansion is expected to bring in new revenue for the providers but also increase the number of patients needing behavioral health services. States are also changing their billing practices to be able to tap reimbursement from the payers associated with the new private plan coverage options. The focus is on easing the burden on state general funds of providing services that would otherwise be funded through Medicaid or commercial insurance.
Kentucky has provided funds to their regional boards to encourage patient enrollment in either Medicaid or commercial insurance. Kentucky has enrolled more than 10 percent of its
population for coverage, mostly under Medicaid. Some of the projected savings to the state general fund from expanding Medicaid coverage has been offset by Kentucky SBHA budget reductions. Because the SBHA’s responsibility for paying for services has been greatly diminished, its role in Kentucky is in transition. It is now paying regional boards to enroll consumers in insurance. It is also working more closely with Medicaid as an advisor on mental health issues.
Arizona is requiring community-based mental health service providers to enroll uninsured individuals when they visit emergency departments (EDs). Maryland has found that most of the people who used the Maryland Health Insurance Marketplace qualified for Medicaid rather than commercial insurance. Maryland’s ASO, which pays for claims, is also responsible for
determining Medicaid eligibility. This process ensures that Medicaid pays only for the services
AZ, KY, MD, OK and WA are
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for which it is responsible and block grant funds are used to pay only for those services not covered by Medicaid.
Maryland officials reviewed the state health care system to assess integration of mental health, substance use disorder, and physical health care. Mental and substance use disorder authorities had developed their service and funding systems along different lines, with the former carved out and the latter carved in. The newly implemented ASO will be responsible for giving providers information about the Medicaid eligibility status of consumers seeking service and for notifying providers when an uninsured applicant may be eligible for Medicaid and should be referred to the appropriate eligibility authority. This strategy has proven effective in the administration of mental health services, ensuring that the SBHA does not pay for services that are the
responsibility of Medicaid. The new ASO will collect data on all mental and substance use disorder services.
1.2 Adjusting Billing Practices and Expanding Health Information Infrastructure
Arizona was the first state to implement a statewide behavioral Health Information Exchange (HIE), but providers also use their own electronic health records (EHRs). The providers in the state’s urban areas have more sophisticated EHRs than those in the rural and remote areas. The state has established standards that allow the EHRs to connect with each other and, when possible, share clinical records. To encourage the adoption and continued operation of EHRs, especially those that meet the meaningful use standards, Arizona is allowing the managed care entities to build the costs of EHRs into their contracts at the rate of 4 percent for implementation and 8 percent for operating costs. Arizona will use the Medicaid billing system for managed care entities, which allows the SMHA to collect and track data on the consumers served.
Maryland was one of the first states to adopt EHRs, although they were for physical health care rather than behavioral health. Most of their large behavioral health providers now have EHRs, which report to the state’s mental health outcomes system. Only the small providers, individual practitioners, and many of the substance use disorder treatment providers do not yet have EHRs.
To address this, Maryland has built health information technology costs into their ASO contract, including the costs of data reporting.
Each of Oklahoma’s community mental health centers (CMHCs) has an EHR, which the state helped the providers purchase. Oklahoma also has one of the longest functioning HIEs in the country, and all CMHCs contract with it. Some CMHCs need to upgrade their systems, but Oklahoma’s Grand Lake CMHC was the first behavioral health facility in the country to meet federal meaningful use standards.
Washington created a massive linked analytic database across Medicaid, state substance use disorder and mental health services, criminal justice, and social welfare agencies. The database allows the state to analyze the outcomes and financial payoffs from providing substance use
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disorder and mental health services. This initiative was started many years prior to the national efforts to establish HIEs, and it demonstrated the feasibility of doing cross-system data linkage.
1.3 Improving and Strengthening Relationships With State Medicaid Agencies
The Arizona SBHA has a strong relationship with its state Medicaid agency, and this relationship facilitates coordination and integration of behavioral health with physical health services.
Arizona’s SBHA credits this strong relationship to constant communication between the
leadership and staff of the two agencies. The Kentucky SBHA’s relationship with Medicaid has become more integrated as the two agencies work together on regulations and State Plan
Amendments. In Kentucky, the SBHA acts as an advisor to Medicaid, because Medicaid funds do not pass through the SBHA. In Oklahoma, a strong relationship between the SBHA and the state Medicaid agency has developed around sharing data. Maryland has been working
collaboratively with their state Medicaid agency for many years. They use the ASO system to pay for services and help meet the data needs of the SBHA and Medicaid. The Washington analytic system is used for evaluation purposes and to demonstrate how reimbursement of substance use disorder and mental health services (e.g., by Medicaid) yields improved outcomes across many service systems of the state.
2. Barriers Experienced
Arizona described 42 CFR Part 2,7 the substance abuse rule limiting the sharing of patient
information for patients being treated for substance use disorders, as an antiquated regulation that hinders the development of more robust health information networks that would allow for greater coordination of care across mental health, substance use disorder, and physical health care.
Other states interviewed also cited 42 CFR Part 2 as a major barrier to sharing EHR data with physical health care providers and among behavioral health systems. In Maryland, 42 CFR Part 2 is cited as a barrier for substance use disorder treatment providers because in order to comply they cannot adopt the state’s EHR system that allows for extensive data sharing. Maryland officials feel that these restrictions impede their ability to provide good-quality, holistic care because providers cannot share data that may be vital for treatment planning. In Oklahoma, 42 CFR Part 2 limits the ability to link behavioral health records. Oklahoma HIEs will only share treatment records if all treatment records are available to be shared. This is in part because there is no consent registry, which makes it impossible to determine with whom individuals have consented to share information. In Washington, 42 CFR Part 2 was not considered a problem because the system is used for research and the ultimate data set is de-identified (a process in which data that can be used to identify specific individuals is removed).
Arizona officials have encountered difficulty in fully understanding the extent to which its population is now covered by commercial insurance, as enrollment has been slow. The SBHA
7 Code of Federal Regulations. Title 42: Public Health. Part 2, Confidentiality of alcohol and drug abuse patient records. Retrieved from http://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=42%3A1.0.1.1.2
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feels that this creates a potential barrier to quickly determining when services are not covered by insurance. It also limits the ability to capitalize on enrollment opportunities, such as when uninsured individuals seek treatment in EDs.
Electronic health records and the electronic sharing of EHR information are important to improving business practices. However, the high capital costs of purchasing and implementing EHR systems can be a major impediment to their implementation by small community
behavioral health providers.
3. Lessons Learned
States shared the following lessons:
It is important to have a strong relationship between the SBHAs and the state Medicaid agency.
Ensure that the skill sets of staff match the changing needs of the agency.
Create clear service definitions and standards.
Engage consultants early in the process to assist states in adjusting to new business processes.
Being among the last states to implement can be advantageous if you learn from the mistakes and successes of others.
The appropriate use of health information technology (HIT) can be the backbone of successful system transformation.
It takes much more time and work than states anticipate up front to do things right.
To make transformation work, establish a working model early.
Technology is easy, but it is difficult to create cultural change in the use of information and to work across systems.
A strong HIT capacity can facilitate more rapid and more effective innovation by arming legislative champions with better data, outcomes, and summaries.
The churn of individuals between Medicaid and commercial insurance creates service delivery problems.
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