Kay Roberson didn’t want anyone to know she had been diagnosed with mental illnesses — not even her medical providers.
So when the Vancouver woman found herself in the local emergency department, she kept her diagnoses a secret. The physicians treating her had no idea she was on powerful medications for dissociative identity disorder, bipolar disorder and anxiety disorder.
“It was dangerous because some of those meds can interact,” Roberson said.
But, at the time, Roberson was more concerned about how she would be treated by medical providers. She was a Medicaid member diagnosed with mental illnesses. She wanted to believe providers wouldn’t judge her, but she knew some doctors would attribute her physical issues and concerns to her mental illness.
Fortunately for Roberson, her decision to hide her diagnoses and medications never had negative health repercussions. But Roberson would like to see that decision taken out of the hands of patients. She wants to see psychiatrists talking with cardiologists and primary care providers and substance abuse counselors. She wants health care to be about caring for the whole person, not one set of providers caring for the head, while another set cares for the body.
The state Health Care Authority — which oversees the Medicaid program, Apple Health — Medicaid health plans and county providers want to see that, as well.
That’s why this month, Clark and Skamania counties became the first in the state to fully integrate Medicaid services. As of Friday, Medicaid clients in Southwest Washington have just one organization managing their physical health, mental health and chemical dependency services. The rest of the state will follow suit over the next four years, with every county in the state providing integrated care to Medicaid clients by January 2020.
In the meantime, all eyes are on Southwest Washington.
“Clark and Skamania counties should be really proud of the fact they’re going first with this,” said Peter Adler, president of Molina Healthcare of Washington, a Medicaid-managed care provider. “That doesn’t mean there won’t be some bumps in the implementation of this. But this is the future of managed care, of Medicaid.”
For years, two state agencies — the Health Care Authority and the Department of Social and Health Services — oversaw Medicaid services. The agencies contracted with various regional organizations, counties and health plans that, in turn, contracted with local providers to serve Medicaid clients.
That meant Medicaid patients had to navigate multiple systems to receive medical, mental health and chemical dependency treatment. It also meant providers worked in silos, unaware of what other services and treatments their patients were receiving, unless the patients told them.
Once Roberson felt confident enough with herself and her mental health diagnoses, she began asking her primary care provider and her psychiatrist to talk. She gave permission for them to share information about her, offered to sign a waiver, whatever it took to get her care team communicating.
“It was a brick wall,” she said. “The Medicaid system, I don’t believe they’re set up to communicate.”
Two years ago, the state took the first steps to try to break down those silo walls.
During the 2014 legislative session, the Legislature passed two bills that, in part, created regional service areas across the state and required full integration of the financing and delivery of Medicaid services by January 2020.
The 10 regional service areas in the state had two choices to move toward Medicaid integration. They could first integrate mental health and chemical dependency services by April 1, 2016, and then integrate physical health in 2020. Or regions could choose to be an early adopter and pursue full integration by April 1, 2016.
The Southwest Washington region, which includes Clark and Skamania counties, was the only region to pursue early adopter status.
The region did have incentives to move forward with the early adopter model. Not only would the counties be able to help craft how the new system operates, but the region will also receive 10 percent of the savings realized through care integration. It’s unclear how much — and when — that money will come to the region.
So now, for the first time, the county’s two health plans — Molina Healthcare of Washington and Community Health Plan of Washington — are responsible for the whole-person care of local Medicaid clients, rather than just their physical health care. A third organization, Beacon Health Options, will handle behavioral health crisis services.
The goals of the integration effort are better health outcomes, better care and lower health care costs. The theory is those goals can be achieved through better coordinated care.
“It’s better care, better outcomes in terms of health and treating the whole person, and it’s better stewardship of the public dollars,” Adler said. “It’s much more expensive to provide fragmented care with lots of redundancies than it is to provide integrated care.”
Preparing for change
In Southwest Washington, Molina has nearly 82,500 Medicaid clients and Community Health Plan has about 15,900 members. The vast majority of those members live in Clark County.
Since the Health Care Authority awarded the contracts to the plans in mid-November, both plans have been preparing to take over the management of mental health and chemical dependency services.
Health plan officials have had regular meetings with state officials and representatives from the organizations that previously administered behavioral health services to ensure electronic patient records are transferred and to share information about how programs are funded and operated.
Molina officials have also been expanding the plan’s provider network, adding all of the mental health and chemical dependency providers who had contracts with the previous organizations managing those services. That means Molina Medicaid members won’t have to change providers and won’t see any interruptions in care under the new integrated system, Adler said.
Molina has also focused on community outreach to inform members of the upcoming changes. Molina has worked with schools to sponsor family nights and food banks during distribution events, where Molina officials can explain the new system and answer questions.
In addition, Molina opened a Vancouver service center and retrained call center representatives and case managers to be better equipped to address mental health and chemical dependency service needs. All member materials have been redesigned — and translated to several languages — to include information about the additional services.
Community Health Plan of Washington also opened a Vancouver office and has contracted with the predominant behavioral health providers in the region, which means members should have access to their previous providers. Those who are seeing a provider outside of the network will have a grace period during which they can continue to see their previous provider before they need to switch to an in-network provider, said David DiGiuseppe, Community Health Plan’s vice president of population health.
The county’s behavioral health providers also have been preparing for the change.
Columbia River Mental Health, which provides mental health and substance abuse services, months ago started reaching out to primary care providers to begin building relationships, said CEO Craig Pridemore.
Earlier this year, Columbia River Mental Health and Rose Medical Groups opened their first joint office in Battle Ground. There, patients can access primary care and mental health services — and, soon, substance abuse services — under one roof.
The office, Pridemore said, is ground zero for integration efforts. Sharing the space allows providers to get to know each other and understand each others’ work, he said.
“Primary care has very little understanding of behavioral health, and behavioral health has very little understanding of primary care,” Pridemore said. “So getting those cultures to interact is very advantageous to integrated care.”
Opening up the lines of communication between providers and the health plans has also been beneficial, said Bunk Moren, executive director of Community Services Northwest, which provides mental health and substance abuse services.
Moren said he’s looking forward to working with the health plans to the benefit of patients, particularly those with complex needs. In the past, it was difficult getting service payers to understand complicated cases — such as people with behavioral health needs, as well as ongoing health issues and social needs — because they were only responsible for funding one aspect of the patient’s care, Moren said.
“These (health plans), they’re gonna see the whole thing,” he said. “They’re gonna see the complexity of the picture through the claims.”
But while most involved are optimistic, everyone acknowledges the transition is likely to come with hiccups.
“When you make any major change like this, there’s going to be bumps in the road,” said MaryAnne Lindeblad, the Health Care Authority’s Medicaid director.
The state and health plans have an early warning system in place to monitor key indicators that could point to problems so resolutions can be found quickly, Lindeblad said.
But the work doesn’t end with the early adopter launch, said Vanessa Gaston, director of Clark County Community Services, which administered substance abuse services under the old system.
“Early adopter is the first step, but it’s not the final step,” she said.
The next step is to get social services agencies involved to address Medicaid members’ social needs, such as housing and transportation, to make addressing their health needs easier, Gaston said. State officials agree.
“People with serious mental illness die sometimes up to 25 years earlier” than someone without mental illness, Lindeblad said. “They don’t die from the mental illness. They die from diabetes and high blood pressure and other health issues that go unaddressed.”
Roberson, who works as a peer mentor for Clark County Crisis Services, hopes those efforts shift more toward prevention, catching people before they reach crisis and their care becomes more complex and more expensive.
“My concern is they’re not there yet,” Roberson said. “They don’t get it.
“What they’re doing is great and longtime needed,” she added, “but they need to do 30 percent more.”