This article is the latest in the Health Affairs Forefront major series, Medicare and Medicaid Integration. The series features analysis, proposals, and commentary that will inform policies on the state and federal levels to advance integrated care for those dually eligible for Medicare and Medicaid.
The series is produced with the support of Arnold Ventures. Included articles are reviewed and edited by Health Affairs Forefront staff; the opinions expressed are those of the authors.
The series will run through August 30, 2022; submissions are accepted on a rolling basis.
Individuals who are dually eligible for Medicare and Medicaid experience higher rates of chronic illness, behavioral health conditions, and social risk factors than those who are eligible for only one program or the other. Duals are three times more likely to both report poor health than Medicare-only beneficiaries. Particularly striking is the difference in behavioral health conditions: Duals are three times as likely to live with a mental health diagnosis compared with Medicare-only beneficiaries. In turn, those living with behavioral health conditions often experience high rates of comorbidities of chronic health conditions. For dually eligible individuals with behavioral health needs, these issues are amplified due to the fragmentation and lack of service delivery coordination between Medicare and Medicaid.
Most dually eligible individuals navigate across programs using different Medicare and Medicaid benefit cards, effectively serving as their own care coordinator by communicating with providers who may not accept one or the other program or have access to beneficiary health care information from different providers. Further complicating an already fragmented system is that Medicare and Medicaid cover different behavioral health services. And physical and behavioral health care are often provided in different systems, which can reduce care access and worsen health outcomes and diminish care coordination for other services.
The COVID-19 pandemic worsened vulnerabilities and health disparities for dually eligible individuals living with behavioral health conditions twofold. First, compared to Medicare-only beneficiaries, duals were three times more likely to be hospitalized due to COVID-19. Furthermore, COVID-19 drove increased rates of anxiety and depression across the country while simultaneously decreasing access to behavioral health services. These challenges have had a significant impact on dually eligible individuals under age 65, a group for which behavioral health conditions are more common, because this group tends to qualify for both programs due to a disability. Medicaid beneficiaries between ages 19 and 64—many of whom are eligible for Medicare—experienced a 13 percent decline in substance use disorder (SUD) treatment utilization and a 22 percent decline in mental health service utilization. This trend was evident in the Commonwealth Care Alliance® (CCA) One Care Medicare-Medicaid Plan (MMP), which serves dually eligible individuals age 64 and younger in Massachusetts; nearly 70 percent of our One Care members have a serious mental illness.
The Promise Of Medicare-Medicaid Integration For Dually Eligible Individuals With Behavioral Health Conditions
Given a complex mix of health and social needs, dually eligible individuals with behavioral health conditions typically require a broad and person-centered range of physical, behavioral health, long-term services and supports, and social services. Integrated Medicare-Medicaid programs, which CCA has provided for nearly two decades via One Care and a Senior Care Options Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP), offer an effective solution to mitigate some of these challenges. Well-designed integrated programs include interdisciplinary care teams and blended Medicare and Medicaid funding in one accountable entity, which has flexibility to build tailored programs.
For example, using blended Medicare and Medicaid funding, CCA created Crisis Stabilization Units (CSUs), which provide a step-down care alternative to psychiatric hospitalization for members experiencing an acute behavioral health crisis who are unable to safely return home. Our CSU beds provide both behavioral health and medical services and have reduced average per diem costs by 33 percent, compared to average inpatient admission costs.
CCA also launched its own Hospital to Home program in which interdisciplinary teams of clinicians, including community health workers and behavioral health clinicians, build relationships with emergency service providers to provide seamless links to CCA’s CSU and members’ homes. Blended funding allows for population-level care management for individuals with complex medical and behavioral health conditions, through consistent assessment and screening for mental health and SUD needs, determination of motivation for change, and implementation of appropriate behavioral and medical interventions without navigating the silos of each funding source.
Federal And State Policymakers Can Improve Behavioral Health Systems For Duals
Despite recent progress—in 2021 about 18 percent of the more than 12 million dually eligibles were enrolled in integrated Medicare-Medicaid programs compared to less than 1 percent a decade earlier—there is more work to be done to advance these programs. States and CMS have two main policy levers to increase the potential for Medicare and Medicaid behavioral health integration:
- Enhance integrated D-SNP models. CMS recently required in its 2023 final Medicare Advantage Part D rule that FIDE SNP models cover nearly all Medicaid services, including behavioral health. States can use State Medicaid Agency Contracts—which D-SNPs must sign with each state in which they participate—to require D-SNPs meet CMS requirements for FIDE SNP status. The inclusion of mental health and substance use disorder services in both our FIDE SNP and MMP models, along with social support services that are heavily utilized by this population, has proven essential for providing high-quality, effective care. Take, for example, a recent anecdote from a CCA One Care member who has a history of substance use, multiple physical comorbidities, and behavioral health diagnoses: Their primary care provider connected them to a Self-Management And Recovery Training support group during a primary care visit. Since the initial connection, the member has increased engagement with primary care and continued to work with recovery coaches as a key element of their behavioral health treatment.
- Design and implement comprehensive Medicaid managed care programs that include behavioral health. Many state Medicaid managed care programs carve out behavioral health benefits from physical health benefits. Integrated financing models in which Medicaid managed care plans manage all physical, behavioral health services, and long-term services and supports can decrease fragmentation, improve health outcomes, and reduce costs. CMS can issue sub-regulatory guidance and offer resources like technical assistance to states to help them use effective behavioral health integration to increase patient engagement and activation and improve patient satisfaction and quality of life.
In addition, there is a role for congressional action. As the pandemic’s impact on individuals with behavioral health conditions becomes increasingly apparent, congressional committees have hosted a series of hearings on the current state of and strategies to address the behavioral health crisis. CCA’s Chief of Psychiatry, Dr. Peggy Johnson, recently testified before the House Ways and Means Committee to describe current barriers and innovations required to meet the behavioral health needs of CCA’s dually eligible members. Congressional committees have recently released and advanced proposals to bolster public health funding for behavioral health care and to improve tele-mental health services and youth mental health. But none of these efforts has become law, and congressional work remains underway to develop behavioral health proposals. As Congress continues to explore various behavioral health reform proposals, we offer recommendations that could have a large impact on how those with complex needs experience behavioral health care and their recovery trajectory:
Expand And Diversify The Behavioral Health Care Workforce
Any congressional action should include efforts to increase supply and quality of the behavioral health care workforce. There is a persistent shortage of psychiatrists, therapists, and other behavioral health providers. Access and affordability are major hurdles for low-income individuals in accessing behavioral health care. Psychiatrists account for the largest share (42 percent) of non-pediatric physicians who opted out of Medicare in 2020, and most psychiatrists (54.5 percent) do not accept new Medicaid patients. There is a nationwide shortage of SUD/opioid use disorder (OUD) treatment providers, which particularly impacts duals who also experience a prevalence of co-occurring SUD and chronic pain twice as high as that of Medicare-only beneficiaries.
Offer Educational And Training Opportunities To Increase Clinical Integration And Provider Capabilities To Offer More Holistic Care
Behavioral health and medical providers often do not have the training, resources, and infrastructure to provide both sets of services to a high-need population with significant comorbidities. In CCA’s experience, inpatient psychiatric units can face challenges with admitting patients with significant medical needs; vice versa, inpatient medical units and primary care practices may be ill-equipped to care for those with behavioral health needs. Provider stigma remains a barrier to care for individuals with mental health and substance use disorders as well. Congress could require and allocate funding for more extensive cross-functional training in medical school and residency programs, as well as other licensing/credentialling bodies across specialties. Innovative approaches can also be adopted more broadly to advance integration. For example, CCA’s interdisciplinary care team model—in which one care partner with expertise that spans the continuum of services coordinates care across various providers—mitigates some of these challenges.
Reduce Existing Barriers To Accessing Behavioral Health Care
Medicare does not cover the full continuum of care for mental health and SUD treatment. Congress could lift the Medicare 190-day inpatient psychiatric hospital services lifetime limit by passing the Medicare Mental Health Inpatient Equity Act of 2021. The majority of Medicare beneficiaries treated in inpatient psychiatric facilities are dually eligible, and those who are close to or have already met the 190-day limit are often deprioritized for admission to free-standing inpatient psychiatric units, which can decrease their inpatient stay options. Additionally, in most states there is no permanent option for Medicaid to cover inpatient psychiatric services in an Institution for Mental Disease (IMD) for adults ages 21 to 64. Integrated programs are best equipped to broaden coverage options available and to share information between inpatient psychiatric settings and Medicaid community-based behavioral health providers who can help keep people at home and out of inpatient settings. Furthermore, making permanent evidence-based pandemic flexibilities to reduce barriers to SUD treatment—such as Opioid Treatment Program flexibilities for take-home doses of methadone and telehealth physical evaluations of patients treated with buprenorphine—can improve patient satisfaction and increase treatment engagement.
Advance State Capacity To Develop And Refine Medicare-Medicaid Integration Programs
Recent bipartisan legislation introduced by the Senate Special Committee on Aging would advance Medicare-Medicaid integration, including for those with behavioral health needs, by requiring states to develop or expand integration strategies. Another related bill from Senator Bob Casey would provide significant funding for states to support these efforts. Increasing the number of states that offer integrated care as well as the scope and scale of current programs will expand the potential for individuals to receive a broad and coordinated range of person-centered physical, behavioral health, long-term services and supports, and social services.
The Path To Integration
As CCA’s Dr. Johnson notes in a related blog post, addressing the behavioral health crisis, especially for individuals with significant needs, will not be easy. COVID-19 illuminated and exacerbated the fragmentation that dually eligible individuals face when accessing services, as well as the consequences of reduced access to key behavioral health supports as the country shut down. Meanwhile, the pandemic also forced policymakers, health plans, providers, and individual consumers to adopt and experience new processes, care practices, and programs. Now is a critical time to connect recent innovation with increasing unmet behavioral health needs to expand integrated, person-centered care.