Robert Wood Johnson Foundation: Depression in Primary Care Initiative: National Meeting, Amelia Island FL

1. Robert Wood Johnson Foundation: Depression in Primary Care Initiative: National Meeting, Amelia Island FL Massachusetts Consortium on Depression in Primary Care (MCDPC) Demonstration February 16, 2006 Challenges for Medicaid Plans

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

3. MassHealth Team • Annette Hanson, MD (former Medical Director), Co-PI • Michael Norton, MSW, MassHealth Behavioral Health Programs, Co-PI • Louise Bannister, RN, JD, Director PCC Plan • Phyllis Peters, MBA, Deputy Assistant Secretary, Acute and Ambulatory Services • Fran Slate, MS, Contract Manager, MCO Plan • Kate Staunton Rennie, MPA, Deputy Director, PCC Plan • Kate Willrich Nordahl, MS, Director MCO Plan Ron Steingard, MD, Medical Director

4. Collaborating Health Plans • Massachusetts Behavioral Health Partnership • PCC Plan • Boston Medical Center HealthNet Plan • Neighborhood Health Plan • Network Health

5. Issues for MCDPC • Plans had different arrangements around behavioral health—carve in, carve out, FFS, capitated; and these evolved during the demonstration time • Significant investment of plans collaborating was made possible by RWJF grant (e.g. monthly meetings); likely not sustainable • Major state budget and plan changes required staff time unrelated to the demonstration project • Significant leadership turnover, Medicaid office reorganizations, and need to defend a federal suit on children’s mental health during time of depression demonstration • Enrollments and over all risk (e.g. disabled members) shifted among plans during implementation period

6. Challenges to behavioral health integration found in MassHealth Plans • Failure of network administrators or plan behavioral health directors to appreciate the extent of patient access difficulties and difficulties for PCPs trying to access BH care on behalf of patients • Limited availability of urgent care appointments in behavioral health resulting in crisis care, ER visits • Up to 50% of patients don’t show up for BH appointments without follow up support • Patients ‘on paper’ were connected to behavioral health but not in fact • Behavioral health rules about compliance push patients out (e.g. if miss certain number of appointments, they will no longer be served) • Behavioral health providers, like primary care, don’t have chronic illness or patient management system in place • Both PCPs and behavioral health providers acknowledged there were no systems for communicating with each other; time investment to do this and lack of financial support for that time an issue as well as lack of guidelines, protocols, expectations

7. PCPs want • Sense that they can get patients connected to behavioral health without undue wait time (applies to both MassHealth and commercial payers) • Medication consultation on short notice/real time—phone or email ‘curbside consult’ without need to wait for patient referral process • Ability to make referral appointments for patients like other specialties • All payers need to be on same page about reimbursement for depression treatment • Needs to be way to work with same team of care manager, psychiatrists, therapists to address patient needs—difficult to develop multiple relationships

8. Intervention tried Care Manager role • CM or PCP office staff able to fax or call in appointment for patient; if BH provider prefers patient to call, CM is notified if call takes place • Information communicated back and forth from practice to BH provider by CM • CM conducts routine follow-up; connects patient to plan based social case management, transportation, community resources • CM monitors all health care needs and keeps PCP informed • CM collects data and follow up PHQ-9 scores Systems changes in behavioral health: • Urgent visits (within 2-3 days) available • Some providers allocated priority BH slots to high volume primary care sites • Regular intake and initiation of therapy within two weeks • Psychiatry medication consultation within 1-2 weeks • Patient asked to sign HIPAA release for CM and PCP practice • BH providers have` information from PCP to assist with patient assessment

9. Sustainable solution across plans • Preferred providers convened along with PCP practice representatives from each plan • Lists of contact information, including ‘inside lines’ and what to do to reach clinician (either PCP or BH provider for patient) in an emergency distributed for practices and BH agencies • PCP practices identify an appointment liaison • Preferred providers agree to accept appointments from PCP practice, not just directly from patient • PCP practices agree to provide PHQ score and other information to the BH provider at time of referral for an appointment • BH providers agree to communicate to PCP practices if patient kept the appointment • BH providers agree to improve communication with PCP practices about patient progress (with appropriate consent)

10. Remaining challenges • How to set this process up across the state • Define and continue role of BH network mangers to link to PCPs • Maintaining communication and connections between PCPs and BH providers with staff turnover • Addressing shortages of specific services, e.g. bilingual therapists, and psychiatrists • Sustaining learning from this project into the future with potential changes in contracting language, new vendors etc. that result in leadership changes

11. Issues specific to Medicaid plans • Lack of continuity of insurance coverage-patients in and out of coverage in frequent cycles due to both administrative and patient factors • Rates paid to providers—both BH and PCP • Biases by providers vis a vis Medicaid • Hard to reach consumers (transient, lose of phones etc.) • More diverse racially/ethnically/linguistically • More psychosocial challenges that medical care can’t address (food security, housing problems, disabilities, etc.) • Less resources for self-management • Less community-based support resources: cost and other barriers