Horizon Model Makes Behavioral Health the "Quarterback" in Chronic Care Management

Behavioral health and substance abuse management have been challenged for decades by lack of investment and fragmented care systems. Despite the cost- and health-related burden caused by behavioral health issues, physical and mental health services continue to be siloed.

By contrast, evidence shows that integrating behavioral health into primary care creates marked improvement of clinical outcomes and cost savings. However, stakeholders from Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) note there are barriers to integration, such as inadequate training on how to manage mental health disorders. Uncertainty about confidentiality standards and privacy laws can make it hard to relay information between behavioral health and primary care.

"At the highest level, the lack of recognition and accounting for the profound impact of behavioral health on individuals’ physical health has led to a deprioritization of behavioral health coordination in primary physical health settings. Some of this extends from the idea that behavioral health costs only represent about 6% to 7% of total medical expenses while overlooking the fact that underlying behavioral health issues contribute to a significant amount of the total health care spend of the member,” said Nickolas Carros, DSW, LCSW, senior director, Clinical Behavioral Health Services, Horizon BCBSNJ.

​​”All these issues combine with the confusing and complex electronic medical record web that exists today," he said. "The compartmentalized reimbursement often separating physical and behavioral health services makes it exponentially more difficult to communicate across systems electronically.”

The lack of care coordination is of particular concern for patients with serious mental illness (SMI) and substance use disorders (SUDs). Whereas acute forms of mental health and SUDs are characterized by their shorter duration and warrant emegency medical stabilization, more serious chronic illnesses require long-term medication, therapy, and case management to achieve lasting recovery and remission.

Chris Barton, LCSW, Director of Integrated Systems of Care & Network Innovation, Horizon BCBSNJ, noted that the need for long-term management is a critical issue facing populations with chronic behavioral disorders. These patients are less likely to have primary care relationships and are associated with social determinants of health (SDOH) challenges (eg, financial, housing and food insecurities, transportation challenges).

Just as persons with diabetes see blood sugar skyrocket when they stop taking their medication, Barton said that those with chronic behavioral health conditions will likely have an acute psychiatric episode that potentially requires stabilization when treatment needs are unmet. This contributes to a higher total cost of care for patients and health systems.

In examining care coordination efforts, Carros said that Healthcare Effectiveness Data and Information Set (HEDIS) measures, which are used by over 90% of America’s health plans to measure performance on important dimensions of care and services, have placed a greater emphasis on expanding to the intersection of physical and behavioral health.

Focusing on 3 key areas—transitions of care, medication adherence, and monitoring potential adverse impacts of medication by the prescriber—he said that these measures require close communication and coordination of care between physical health and behavioral health providers.

“The best practice interventions look to improve care to members through a seamless coordination of physical and behavioral health services within a holistic 360 degree member approach that coordinates care and holds providers accountable through a quality-based incentive structure for standard medical care, both physical and behavioral,” noted Carros.

Examining Horizon’s “Best Practice” Intervention to Address SMI and SUDs

Prioritizing the 360 degree approach, Horizon BCBSNJ recently designed an Integrated System of Care (ISC) program specifically for beneficiaries with SMI and SUDs that aims to address physical health, behavioral health, and SDOH.

Unlike integrated care models that are built upon primary care relationships and focus on patients with acute forms of disease, Horizon’s ISC program leverages community-based behavioral health providers as the “quarterback” of care. Thus, it's the behavioral health provider who takes the lead in coordinating care and helping patients navigate their physical health care, while addressing social needs and delivering behavioral health treatment and/or case management.

“The ISC providers don’t necessarily deliver all of the care that a member needs themselves; this is not a one-stop model. Rather, the ISC providers are collaborating with community-based primary care practices, behavioral health practices, health systems, and social service agencies to meet the members’ needs,” explained Barton.

“It is essential that health care providers serving members with chronic health conditions establish trust and rapport with their patients, so that they feel comfortable and confident sharing their progress and their challenges in recovery.”

From a value-based contracting perspective, Barton touts the ISC program’s unique reimbursement structure, which bundles case rate and performance incentives that eschew utilization management or prior authorization requirements. Providers are also not restricted to the traditional “levels of care” that have been defined for behavioral health by contracts and state licensure or even traditional behavioral health contracts, she added.

“Rather, this bundled case rate allows the provider to deliver care that meets the member’s goals and treatment needs. That may be some combination of “traditional” behavioral health treatments, along with peer support and case management, and other less commonly used therapies that can traditionally come with higher member out-of-pocket costs. All of this can be delivered via the monthly bundled case rate, at a lower cost to members, and with more flexibility for providers,” said Barton.

Findings of member-reported survey data from the more than 1600 ISC program enrolles collected at admission and every 3 months have shown substantial improvement in SMI and SUD outcomes:

• 61% reduction in tobacco use
• 52% reduction in alcohol use, illegal drug use and prescription misuse
• 47% reduction in mental health symptoms
• 25% improvement in quality of life
  

Furthermore, significant clinical and financial benefits have been observed among enrolled vs nonenrolled patients in the ISC program, including 84% follow-up after hospitalization, 27% lower emergency department utilization, and 21% lower total per member per month costs.

As the model utilizes a pay-for-performance incentive, Barton highlighted that to be successful with this measure and with overall enrollment for the ISC model, providers must maintain collaborative working relationships with local hospital systems—from emergency departments and hospital social workers to primary care and population health management—as these health system partners are critical to member and provider success.

“Our ISC providers have long standing relationships with their local health systems, but the ISC and the built-in performance incentives have made this relationship even more meaningful, moving it from a passive referral process to a bi-directional relationship with active engagement.”

Long-term Implications of Value-based Contracting in Behavioral Care

The supply and demand bottleneck within behavioral health and substance abuse care has been a longstanding issue of utmost importance following the COVID-19 pandemic and recent rollout of the national 988 mental health crisis hotline.

In the past 3 years, the United States has experienced its highest ever rate of opioid overdose per capita and suicide, especially among young people, with financial and social stressors continuing to impact populations nationwide. This coincides with findings of a recent RAND study indicating that approximately 45% of people who need mental health and substance use services do not receive it.

In improving access to and engagement in behavioral health and SUD care services, transitioning to preventive care and value-based payment could not come at a better time, said Barton.

By the end of 2022, Horizon’s ISC program will be accessible to members in all 21 counties of New Jersey, including rural, suburban, and urban communities, either through traditional providers or virtual solutions.

“We believe in caring for the whole person at any age–not just to treat disease, but to prevent it. There is no “one size fits all” approach to behavioral health. Fully integrated behavioral health care means living the values of health parity and health equity—integrating behavioral health care, physical health care, SDOH, and medication management/pharmacy throughout a health plan within the provider’s community,” said Suzanne Kunis, vice president of Behavioral Health, Horizon BCBSNJ.

Kunis added that to realize their vision of integrated health care, her organization has embarked on a journey to philosophically and culturally commit to integration, starting with insourcing their behavioral health clinical program from a traditional managed behavioral health organization.

“As overall wellness becomes a focus, and more people are engaged in routine outpatient care in the same way that they would be engaged with their primary care physician, we hope to see few visits to the emergency department and inpatient care for behavioral health,” said Barton.

“We also hope to see greater community tenure and shorter lengths of stay when members do engage in higher levels of care. And we expect to see greater engagement in medication management and primary care collaboration. These are all indicators of quality care.”