Tennessee’s Combined Behavioral, Medical Care Grabs NJ’s Attention

Andrew Kitchenman | July 16, 2014 | Health Care
Advocate wants to see state draw lessons from care coordination provided by TennCare

Keith Gaither directs managed-care operations for TennCare, Tennessee’s Medicaid office.
When New Jersey changes how it manages behavioral healthcare services for Medicaid recipients, it may want to turn to Tennessee for lessons

That’s the case being pitched by New Jersey healthcare advocates, who note that the conventional separation of behavioral healthcare and medical care can lead to inefficiency and poor health, since patients often require both types of care.

For example, Tennessee found that the insurers that separately paid for behavioral health and medical care would argue with hospitals over whether a patient’s condition was primarily behavioral or medical. For patients with chronic conditions — such as depression and diabetes — this made little sense, since each condition can feed the other.

As a result, Tennessee decided to combine both types of care under the same managed-care program. The result has been impressive, according to both Tennessee officials and healthcare policy advocates in New Jersey.

Instead of seeing behavioral and physical health as separate issues, Tennessee and its insurers have emphasized coordinating all of a patient’s care, so that patients with both medical and behavioral problems can improve in both areas.

“Providers were concerned that behavioral-health costs would be short-shrifted and that was not the case at all,” said Dr. Charles Freed Jr., chief medical officer of behavioral health services for the UnitedHealthcare Community Plan in Tennessee.

Instead, insurers found they could realize significant savings if they funded patients’ behavioral healthcare early, which has led to a reduction in inpatient hospital stays.

The Good Care Collaborative, a New Jersey-based coalition of healthcare providers and advocates, is highlighting Tennessee as a role model for New Jersey, as part of a broader effort to reform how Medicaid is funded and works in the state.

The push comes at a time when New Jersey’s Medicaid officials have been planning to put a single insurer — or administrative services organization (ASO) — in charge of payments to behavioral health providers. The state currently contracts directly with behavioral health providers.

Dr. Jeffrey Brenner, executive director of the Camden Coalition of Healthcare Providers, said a separate ASO isn’t what’s needed and that the state would make things simpler for itself and better for patients by combining managed care for behavioral healthcare with medical care. He noted that while the funding of healthcare may be a technical problem, its results are fundamental to the delivery of care.

“It’s very hard to integrate service if you do not integrate the administration and financing of care,” said Brenner, whose organization is a member of and helped organize the Good Care Collaborative. “How can we expect the front-line primary-care provider and a front-line psychologist in Camden to be collaborating across organizations, when above them none of the administrative structures and payment structures are integrated? Tennessee is way out on the cutting edge of that.”

While Tennessee has given insurers an incentive to provide efficient, effective behavioral healthcare — since it can lead to lower medical costs in the future — Brenner said New Jersey has no such incentive in place for its behavioral providers.

The collaborative hosted a webinar that included Tennessee state officials and UnitedHealthcare representatives yesterday. They discussed the benefits of Tennessee’s experience, which began when Medicaid behavioral health was included in managed care in 2007. While New Jersey has insurers manage care for Medicaid medical care, it still pays behavioral health providers directly through contracts.

Keith Gaither, who directs managed-care operations for TennCare — Tennessee’s Medicaid office — said combining the two types of care into managed care led to more strategic thinking about how to improve residents’ health.

“It allowed us to move away from disease-management protocols and toward a population-health model,” in which the focus is on keeping patients healthy rather than primarily treating them when health crises occur, Gaither said.

Freed said the attention that UnitedHealthcare paid to behavioral-care plans led to the insurer being in an unusual position: It was actually asking hospitals to delay discharging patients to ensure that a proper plan was in place to prevent future crises.

UnitedHealthcare has also invested in care managers visiting patients — sometimes in teams — rather than just managing care over the telephone, according to Tricia Lea, the company’s Tennessee behavioral health executive director.

Brenner said the time for New Jersey to act is now. “We’re falling further and further behind the rest of the country,” he said.

He added that retirements, hiring freezes, and staff reductions in the Department of Human Services has left the state ill-prepared to make necessary changes. While Gaither said Tennessee could roll out changes to Medicaid managed care in a few months, Brenner said it takes New Jersey years to adjust.

Brenner argued that combining behavioral healthcare in New Jersey’s managed-care program would reduce the need for state officials to continuously review its behavioral-health plans.

It would also allow them to concentrate on determining which services it would ask the insurers that oversee managed care to provide. The Good Care Collaborative has been highlighting several services that have a track record of successfully coordinating patient care, including the Nurse-Family Partnership and the Ryan White Program.

“You need a state that can procure and ask for what it wants, and vendors that can deliver the service,” Brenner said.