Sustaining & Expanding Integrated Care in Montana

This week, in partnership with the National Council for Behavioral Health, we released a report that gives recommendations for how integrated care can be sustained and expanded in Montana.

The Montana Healthcare Foundation’s Integrated Behavioral Health Initiative is transforming the standard of care for primary care providers and patients in Montana. We commissioned the National Council for Behavioral Health to assess options the State of Montana could explore to ensure the sustainability and ongoing expansion of the integrated care model in Montana. This report, “Sustaining and Expanding Integrated Care in Montana,” provides recommendations for finance, policy, and workforce changes.

The integrated behavioral health model involves three components: primary care, behavioral health care, and care coordination. While primary care and behavioral health services are generally directly reimbursable by insurance, care coordination is less often reimbursed, making the model challenging to sustain. The report examines options for addressing the behavioral health workforce shortage and optimizing reimbursement for providing high-quality, effective integrated behavioral health services in primary care. The report offers detailed recommendations. Among the most promising are:

Participate in Primary Care First

In 2021, providers participating in the Centers for Medicare and Medicaid Services (CMS) Comprehensive Primary Care Plus (CPC+) model will be eligible to participate in the new Primary Care First model. Primary Care First builds on CPC+ but will offer providers more flexibility to design effective services by providing a per member per month payment. Primary Care First is a “risk-based” model in which providers receive adjustments to reimbursement levels that reward high-quality care and improve health outcomes. Participation in Primary Care First could offer high-performing integrated behavioral health practices a way to sustain this model of care.

Revamp Montana’s Passport to Health and Patient-Centered Medical Home programs to support increased care coordination

Montana’s longstanding Passport to Health program is not taking full advantage of the tier-based payment system currently available to support value-based, outcome-driven approaches. Updating Passport to Health to align reimbursement with the goals of implementing integrated, team-based care and improving value and outcomes would strengthen the program. A per-member, per-month reimbursement rate could be developed based on a staffing model for a team that serves a standard number of patients and provides care coordination.

Similarly, Montana’s Patient-Centered Medical Home (PCMH) program has a tiered support system that can be fully implemented by primary care practices. The tiers allow practices to receive increased payment for care coordination. Some practices are not currently using PCMH, and those that do are not using the highest tier. Providing technical assistance and education to practices may help increase adoption so that they can effectively use each element of the program.

Consider developing a Medicaid Health Home program

The Affordable Care Act created an optional Medicaid State Plan benefit that allows states to establish Health Homes that integrate and coordinate primary and specialty behavioral health services to improve outcomes and reduce the costs of care for people with complex, chronic health conditions.

Montana could establish Health Homes in primary care practices. Illnesses that are commonly seen in primary care (like diabetes, depression, anxiety, and substance use disorders) are included as eligible conditions. The Health Home model would allow primary care providers to be reimbursed for providing integrated behavioral health services – including care coordination – to Medicaid patients.

Reimburse in-training practitioners

A shortage of behavioral health providers limits the adoption of integrated behavioral health, particularly in rural areas of Montana. In-training practitioners are behavioral health practitioners who have finished their schooling and are working under the supervision of a licensed provider to meet the clinical hour requirements for licensing. Currently, prospective payment system hospitals (our largest hospitals) and critical access hospitals (our smaller hospitals) cannot bill for in-training practitioner services, which creates a barrier to implementing team-based primary care in these settings.  

Allowing reimbursement of in-training practitioners in hospital-based primary care practices would help the available workforce provide services where they are needed most – in Montana’s rural areas.

Increase reimbursement rates for screening, brief intervention, and referral to treatment for substance use disorders

The U.S. Preventive Services Task Force recommends using screening, brief intervention, and referral to treatment (SBIRT) for substance use disorders (SUD) because it has been shown to improve SUD outcomes. SBIRT requires time and training to do well, but the reimbursement rate for this service in Montana is low so there is little incentive for primary care practices to implement SBIRT routinely. Given the rate of alcohol use and SUD in Montana, improving reimbursement could improve outcomes by incentivizing effective prevention and early intervention.   

The integrated behavioral health model improves health outcomes and reduces care costs by providing coordinated care that treats each person as a whole, addresses social and economic barriers to health, and tracks outcomes to ensure effectiveness. Implementing this model of care well requires a well-trained, talented staff that includes functions that are not directly reimbursed by most insurance coverage. Despite the challenges and reimbursement shortfalls, dedicated, innovative providers around Montana have committed to providing integrated care and have begun implementing this model because of the benefits for patients. The policy changes detailed in this report will help these practices sustain and strengthen this model and ultimately improve people’s health outcomes across the state.