Many state and county Medicaid programs are considering the implementation of managed care models in their behavioral health care systems in order to ensure consistent quality outcomes for their residents with a mental health condition or substance use disorder. As a national leader in managed behavioral health care services, Optum has helped states and counties transform their behavioral health service systems to provide clinically effective, and cost-effective, evidence-based and person-centered care for their populations.
Transitioning to a managed system of care requires coordinated efforts among all local stakeholders, and Optum recommends a four-step framework for supporting this transformation. This includes: 1) ensuring clinical excellence; 2) establishing partnerships with covered members, families, and communities; 3) collaborating with providers; and 4) enhancing and expanding programs and services. This approach has helped states and counties improve the quality of care, as well as increased the satisfaction among those who receive and provide clinical services.
In order to ensure clinical excellence, it is important to promote the use of evidence-based best practices that have demonstrated positive outcomes. Multiple states, including Utah and Idaho, have implemented managed care solutions and partnered with Optum to promote evidence-based guidelines across their programs and services. This approach is fostered though consultation and education to assist behavioral health and primary care providers on the implementation and adoption of these guidelines.
As an example of improving clinical services, Optum has implemented effective outreach and access resources through crisis lines that provide clinician availability 24/7 in select areas. These services help facilitate the referral of people in mental health crisis to effective treatments that promote evidence-based care and support recovery. In San Diego County, California, Optum’s management of the access and crisis line has been commended by Michael Reading, Board Chair of CONTACT USA, a leading organization that accredits crisis line services.
Clinical excellence is also achieved through partnerships with covered members, their families, and communities. Optum has recognized the need for empowering people to play a key and decisive role in their behavioral health. Engagement in care is promoted through the involvement of members and their families in the development of resources and strategies to foster recovery and resiliency. For example, Optum has conducted trainings across the state of Idaho with covered members and their families on the key role they have in effective care planning. Furthermore, in both urban and rural communities across the state, Optum has conducted Mental Health First Aid training to help community members learn how to recognize and better understand someone who is experiencing a mental health crisis. This training also enables community stakeholders—including those working in social services, law enforcement and first responders, school faculty, and others—to help people in crisis access the appropriate behavioral services they need.
Transforming systems to managed care models also requires effective provider collaborations. One way Optum achieves this is by working with local provider organizations to develop joint advisory committees that are actively involved in the identification and implementation of evidence-based and person-centered services in the community. When gaps in services are found, Optum works with providers in these identified locations, to provide the necessary training and education, as well as the design and implementation of new service programs, in order to fill the need.
Optum has found that such partnerships are greatly valued by the providers themselves, as they are able to actively participate in improving their services and outcomes. In Idaho, Kim Dopson, former Clinical Director of Proactive Advantage Behavioral Health (a community-based network provider), has reported that “Optum Idaho has been an excellent proponent and accessible partner in supporting the transformation of our practice, our providers and our profession. Transforming the mental health care system in Idaho has meant applying national best practices that are grounded in recovery-focused, evidenced-based treatment.”
Enhancing programs and services involves the expansion of resources for covered members, including peer support services, level-of-care transition programs, and community-based supports, among others. As an example, peer support services have been recognized by the Substance Abuse and Mental Health Services Administration (SAMHSA) for increasing a person’s likelihood of mental health and substance use recovery. These services are provided by individuals who have personal experiences with mental health or substance use conditions, and are trained and generally certified to use their experiences to engage and support people in their recovery journey. These services can range from helping people develop and work on recovery plan goals, to setting follow-up appointments with mental health providers, to connecting people to support groups and other helpful resources.
Implementing peer support programs as a service enhancement helps achieve improved recovery outcomes and reduce costs by fostering community tenure and reducing the need for inpatient care. An Optum-covered Medicaid member who has recently begun to receive peer support services has noted that “I finally feel like I can actually do this. I am not ashamed of who I am, and I know there are other people in the world just like me who are thriving, and I can too.” (Source: Idaho Behavioral Health Plan survey response.)
As states consider implementing managed care solutions to transform their behavioral health systems of care, their strategy may also include the method they reimburse clinical services. Optum has observed a growing interest among state and county stakeholders in shifting payment models to focus on value-based reimbursement and population health management. Optum believes that incentive-based contracting, one that rewards provider systems for meeting clearly defined clinical metrics for positive care outcomes, is the best way to promote quality-driven, person-centered care. In fact, Optum has implemented such pay-for-performance provider contracts in several markets throughout the U.S.
Optum has demonstrated that effective implementation of managed care models can improve outcomes while reducing overall costs. For example in Pierce County, Washington, system transformation has resulted in an annual increase of individuals served by over 50% without increasing the total costs of care (based on a 2015 Optum analysis of the results of a redesigned regional support network over a five-year period). This was achieved by improving access to services, and the introduction of peer-based and person-centered services that focused on maintaining recovery and keeping members in the community. This approach has reduced the need for involuntary treatments and hospitalizations, while also reducing the rate of readmissions within 30 days. This system transformation in Pierce County was achieving by following the recommended framework of ensuring clinical excellence, establishing partnerships, promoting collaboration with all providers, and enhancing programs and services.
As states and counties continue to evaluate the quality, clinical effectiveness, and costs of their behavioral health systems, it is important to recognize that improvements are possible. Managed care programs help control costs and benefit all stakeholders across the community. Transforming these systems through effective partnerships helps assure that individuals receive evidence-based, person-centered care focused on positive outcomes and maintaining recovery.
NOTE: Optum does not recommend or endorse any treatment or medications, specific or otherwise. The information provided is for educational purposes only and is not meant to provide medical advice or otherwise replace professional advice. Consult with your clinician, physician or mental health care provider for specific health care needs, treatment or medications. Certain treatments may not be included in your insurance benefits. Check your health plan regarding your coverage of services.