County moves toward integrated care for Medicaid recipients

The approximately 14,000 individuals in Island County eligible for Medicaid benefits will soon have access to integrated physical and behavioral health care.

“Ideally, they could go to one place for several services,” said Jackie Henderson, director of Island County Human Services.

The goal is to have a mental health and chemical dependency professionals in the same building as a primary care physician who can do assessments of patients. Henderson said a staff member would also potentially be available to help guide individuals through the process of getting to the appropriate locations for the care they need.

The no-show rates are high for the Medicaid population, which increases the likelihood of those who need preventative care ending up in emergency rooms, jails or psychiatric hospitals instead, she said. The integration would also include the communication and cooperation of all of these types of medical professionals.

In 2014, the Washington State Legislature passed legislation directing regions to implement integrated services by 2020. The state’s health care authority offered incentives to regions which implement these services by 2019 to become what’s called a “mid-adopter.”

The North Sound region, which includes Island, San Juan, Skagit, Snohomish and Whatcom counties, recently sent the state its letter of intent to become mid-adopters. Every county in the region had to agree in order to move forward and receive the $11.7 million in incentive funding for implementation.

However, the decision by the five counties was conditional.

The letter included a request that the state formalize what’s called the interlocal leadership structure, an organization chaired by county authorities that includes the director of the region’s Behavioral Health Organization, representatives of state managed care organizations, a representative from the Accountable Community of Health and a tribal authority representative.

“I think elected officials all over felt very strongly that, if this groups is going to be spending taxpayer money, there needed to be some elected officials having some say in that,” said Henderson.

The letter requested that the leadership structure be involved in the selection of the managed care organizations, or MCOs, that will serve the region. MCOs are insurance organizations for Medicaid patients and there are five in Washington state. Without this leadership structure, no elected officials will be involved in this decision-making process, as the law is currently written.

Island County Commissioner Jill Johnson said this request came out of a concern by counties that high-cost costumers would be considered less desirable by the MCOs, leaving that population under served.

The region also requested the ability to establish criteria or MCOs that includes services to people living in “geographically challenged areas.”

“Those are the types of things we’re worried about,” said Johnson. “When you lose control, you can end up with consequences.”

Johnson said she is heavily involved in the process as a committee chair of the North Sound Behavioral Health Organization. Through her communication with the health care authority and representatives from the governor’s office, Johnson said she feels confident that conditions regarding the leadership structure will be formally recognized.

“A lot of people have a lot vested in this,” she said. “No one is going to do anything that won’t foster good relationships. Everybody wants a positive outcome”

The other condition is for sufficient dedicated funding to operate the region’s administrative services organization — which will manage crisis services and other related non-Medicaid funding, such as mental health and substance abuse grant money.

Johnson said she is less confident about this condition being met because it requires action by the legislature, and “no one speaks for the legislature.”

It is possible that the state will refuse the conditions and the region won’t become a mid-adopter but will be required to make the same changes in 2020 anyway.

Implementation of these big changes will face significant challenges. Staffing at primary care facilities will have to alter to allow for the addition of behavioral health professionals. The software at these facilities will have to either change or be updated to allow for the exchange of physical and mental health information, said Johnson.

Federally, there is a level of uncertainty around the program. The state created this legislation as a result of requirements under the Affordable Care Act.

Congress recently tried multiple times to repeal and replace this act, and the president has started to take executive action to dismantle pieces of it.

Johnson said these moves haven’t concerned her.

“If the federal money starts to dry up, the state’s still on the hook for this program,” she said.

She said the debate about providing better comprehensive care for these individuals shouldn’t be a partisan issue.

“I can’t think of an argument on any side of any aisle that would think that was bad, and at some point we have to take a step back and separate politics from what these conversations are.”

The geographical barriers are another challenge to the region’s patients.

The change in the system will only “pay for itself” if individuals are receiving necessary preventative care to stay out of high-cost places, such as emergency rooms or jails, said Johnson.

Johnson said providers and the counties are “nervous” about this shift because of the scale of it, but she feels confident it will be made effective.

“There’s a lot of unknowns,” she said. “But there’s that commitment to make it work, and that is the thing that I just keep coming back to.”