Lessons Learned: CalAIM Integrated Care Plans Can Be Replicated Across States
Full integration of physical health, behavioral health, and oral health under one contracted managed care plan can be replicated.
THE VBP Blog
October 26, 2022 – In past VBP blogs, we’ve discussed the unique features of CalAIM and what sets it apart. And while we could write many more blogs on that subject, we realize that our readers are diverse and spread across the country. That is why in this blog, we are going to look at how CalAIM can be used as a road map for other states. In this case, how other states can adopt the fully integrated care model, and what benefits this philosophy can provide.
We know that achieving optimal health outcomes requires more than just quality medical care. In order to achieve the best health outcomes possible, non-medical needs to be met. And health care cannot focus on only physical health. Behavioral health and oral health must also be addressed in whole-person, integrated care plans.
This coordination and integration of care is not easy, but that is what the state of California is aiming to do through CalAIM. Keep reading for lessons learned from CalAIM Integrated Care Plans and how your state can benefit from a similar methodology.
(Do you need to catch up on the CalAIM blogs? Find them all here.)
Navigating Complex and Siloed Care Delivery Systems Lead to Poorer Outcomes
Medi-Cal beneficiaries are currently required to navigate multiple complex managed care and fee-for-service (FFS) delivery systems to meet the entirety of their healthcare needs. They receive physical health care and treatment for mild-to-moderate mental health conditions from Medi-Cal managed care plans. County delivery systems provide care for SMI/SED and SUD, while dental care is obtained through FFS or a dental managed care plan. Non-medical needs are an entirely different silo and must be addressed through community organizations and support services.
The issue with this is that fragmentation leads to gaps in care and disruptions in treatment. Fragmentation is not convenient or patient-centered. This complex and siloed method for care delivery is frustrating and often those who need care and services the most, cannot navigate it on their own and thus, do not receive the care they need.
The problem with siloed care is that behavioral, physical, and dental health are all linked. Research shows that people with a mental health issue are more likely to have a preventable physical health condition. Chronic health conditions like diabetes, substance abuse, asthma, obesity, and cardiovascular disease, require behavioral health interventions to obtain the best outcomes. There is also research suggesting that a lack of health care insurance can also be linked to poorer outcomes for both behavioral and physical health.
Even those that do receive care and services while navigating complex, siloed systems can suffer. They might be subject to duplication and higher costs because providers are not aligned and sharing data. While not easy to implement, integrated care models are necessary to obtain optimal health outcomes.
Integrated Care Under One Managed Care Plan Benefits All
Through CalAIM, the California Department of Health Care Services (DHCS) is striving to fix the issue of siloed care and improve health outcomes. DHCS is testing the effectiveness of an approach to provide full integration of physical health, behavioral health, and oral health under one contracted entity. This is the ultimate form of whole-person care and ideal for how value-based structures are implemented.
Under the CalAIM model, the state will secure one contracted entity, to administer and implement health care across the full continuum of care. With coordinated and fully integrated care plans, beneficiaries of CalAIM will be able to receive comprehensive physical, behavioral, and dental health care without navigating multiple delivery systems.
The primary goal of integrated care is to improve the beneficiary experience as well as health outcomes. There are other benefits too, such as administrative simplification and more efficient coordination of care. It also enables opportunities to analyze data to identify and manage the risks and needs of beneficiaries more holistically.
Pennsylvania Takes Steps Towards Coordinated Care
Integrated programs are on the brink of being implemented across the nation. Pennsylvania is one example of this. In 2016, the state launched the Integrated Care Program (ICP) to encourage physical health MCOs and behavioral health primary contractors and MCOs to work more closely together.
The ICP provides financial incentives based on integrated health quality measures to enhance coordination. To receive a payout, at least 1,200 members must receive an integrated care plan by both the physical health and behavioral health MCO.
While it is great to see Pennsylvania taking the steps to provide more coordinated care plans for beneficiaries, care is still siloed between separate behavioral and physical health MCOs. Similarly, LTSS MCOs are required to coordinate care with the Behavioral Health MCOs, however, this has been met with limited success. This leaves consumers struggling to navigate available resources and causes administrative burdens for MCOs. Consumers who could benefit from what integrated care offers are still struggling to see the benefits in Pennsylvania. Through the CalAIM model, states can group all care—physical, behavioral, and dental—under one contracted entity to reduce complexity and increase administrative efficiencies.
Keep an eye out for a more in-depth look at Pennsylvania’s attempts at integrated care in an upcoming blog!
Integrated Care Implementation Cannot Be Rushed
One thing that CalAIM is doing right, is not rushing into an integrated care model that is not well thought out. The California DHCS recognizes the complexity of this model and has proposed a go-live date of no sooner than 2026. This provides ample time for planning and preparation with counties, plans, and all stakeholders. We’ve seen from past roll-outs that time is essential for a successful program change.
It is good to see that DHCS involved stakeholders from the onset. A Full Integration Plans Workgroup was established with an extensive roster. They also sought stakeholder and public feedback and insight through meetings and webinars to help understand the benefits, risks, and considerations for plans and counties interested in participating in a fully integrated care model. Topics of discussion included eligibility criteria for entities, administrative requirements across delivery systems, provider network requirements, quality, and reporting requirements, among others.
For states that are looking to CalAIM as a model for their own integrated care models, it is important that they too include stakeholders in the process and do not rush the planning and preparation of such a large undertaking.
Optimal health outcomes require full integration of care. We can no longer rely on the old philosophy that care should be siloed. Instead, we need a full integration of physical health, behavioral health, oral health, and non-medical social determinants of health. But how do we coordinate and successfully integrate care? CalAIM has designed a mechanism to provide full integration of care through one contracted managed care plan entity and is currently going through an active stakeholder participation process to inform the development of the various components of fully integrating health care services. They are not rushing the process and are actively engaging those involved in the process. This is something other states should keep an eye on—the XtraGlobex team certainly will—as doing so removes barriers and the complexity that beneficiaries face when trying to have all of their care needs met.
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About the Author
Fady Sahhar brings over 30 years of senior management experience working with major multinational companies including Sara Lee, Mobil Oil, Tenneco Packaging, Pactiv, Progressive Insurance, Transitions Optical, PPG Industries and Essilor (France).
His corporate responsibilities included new product development, strategic planning, marketing management, and global sales. He has developed a number of global communications networks, launched products in over 45 countries, and managed a number of branded patented products.
About the Co-Author
Mandy Sahhar provides experience in digital marketing, event management, and business development. Her background has allowed her to get in on the ground floor of marketing efforts including website design, content marketing, and trade show planning. Through her modern approach, she focuses on bringing businesses into the new digital age of marketing through unique approaches and focused content creation. With a passion for communications, she can bring a fresh perspective to an ever-changing industry. Mandy has an MBA with a marketing concentration from Canisius College.