Value-based care models are rapidly becoming the preferred approach for improving quality and lowering the cost of care for Medicaid members in managed care organizations (MCOs). These models are a key component in the delivery of high quality, holistic and integrated health services.

A white paper from the Anthem Public Policy Institute, Medicaid Managed Care for Individuals with Mental Health Conditions and Substance Use Disorders: Emerging Use of Value-Based Care Models, notes that these models may be especially beneficial for members with mental health conditions and/or substance use disorders (MH/SUD), yet they have not gained widespread adoption with MH/SUD providers.

Historically, Medicaid members with MH/SUD have received care and services in a system that rewards providers for volume of care, rather than quality of care such as prevention and improved outcomes. Additionally, these individuals have had to navigate a siloed system of care with disparate providers for behavioral and physical healthcare.

Too often, Medicaid beneficiaries with MH/SUD have poorer health and social outcomes, higher rates of costly co-occurring physical conditions, and higher costs of care. It is in this context that value-based care models may represent a particularly important tool for improving care for Medicaid members with MH/SUD.

Adoption of value-based models in behavioral health is growing

According to a report by the Medicaid and CHIP Payment and Access Commission (MACPAC), one in five Medicaid members has been diagnosed with a mental health condition and/or substance use disorder. As a result, Medicaid MCOs are increasingly looking toward value-based care models such as pay for performance, bundled payments, shared savings/shared risk programs or accountable care organizations (ACOs), to integrate behavioral and physical health benefits. These models encourage both mental and physical health providers, as well as social support specialists, to focus on the whole health of a patient, and to break down the silos that traditionally divide mental and physical healthcare payment and delivery.

The trend toward value-based care models in Medicaid managed care for members with MH/SUD is encouraged by many factors, including:

  • Growth in Medicaid enrollment, which is overwhelmingly driven by newly eligible adults enrolled in MCOs, many of whom are at risk for MH/SUD.
  • More robust mental health and substance use disorder benefits in Medicaid, which have grown in large part due to the ability of MCOs to manage and coordinate benefits.
  • Focus on integration, apparent in many states, which are moving to models which fully carve-in benefits, and leave the management and integration of physical health, mental health, SUDs and pharmacy benefits for members to the MCOs in the area.
  • New requirements for use of value-based payments, which promote state accountability for Medicaid waiver funds.

Measurement is essential to assess the efficacy of these programs

In order to further advance value-based models that promote integrated care for Medicaid members with MH/SUD, it is crucial to understand which approaches improve the delivery of care and outcomes. A key piece of this effort is establishing appropriate and accurate quality metrics that provide insight into the effectiveness of the models. However, there are some challenges to accurate measurement for these programs, including:

  • Limited number of measures focused on mental health and substance use disorders and even fewer that address integration of MH/SUD and physical health
  • Existing measures tend to be focused on clinical outcomes or effectiveness, while not addressing other important factors, such as social issues, that can influence outcomes for individuals with MH/SUD

Nevertheless, progress is being made in refining and producing a set of metrics that addresses these gaps.

  • The National Committee for Quality Assurance (NCQA) and the National Quality Forum (NQF) are working with federal agencies to address gaps in mental health and SUD treatment, and to create measures related to benefits integration.
  • In 2015, the Center for Medicaid and CHIP Services (CMCS) added four new quality measures to the core set of Medicaid measures—all of which relate to MH/SUD.

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