Maine Barriers To Integration Study: The View From Maine .
Maine Barriers to Integration Study:The View from Maine on theBarriers to Integrated Care andRecommendations for Moving ForwardJuly 2009AuthorsJohn A. Gale, MSDavid Lambert, PhDMuskie School of Public ServicePrepared forThe Maine Health Access FoundationContract no. 2007CON-0010
Maine Barriers to Integration Study:The View from Maine on the Barriers to Integrated Care andRecommendations for Moving ForwardJohn A. Gale, MSDavid Lambert, PhDMuskie School of Public ServiceUniversity of Southern MaineJuly 2009Prepared for:The Maine Health Access FoundationContract no. 2007CON-0010
AcknowledgementsWe would like to thank the members of the Study Team and Advisory Committee for theirassistance and guidance on this project. Their assistance was invaluable in undertaking thiscomplex study. We also thank the following Muskie School staff for their assistance with thisproject: Karen Pearson, Kimberly Bird, and Melanie Race for their help in editing the finalreport; Lisa Marie Lindenschmidt and Tedda Yeo for their assistance in organizing the meetingsof the Advisory Committee; and Jennifer Lenardson and Diane Friese for their assistance inorganizing the models of care and in conducting stakeholder interviews. Finally, we would liketo thank William Foster, Dean of the Muskie School and Wes Davidson, Executive Director ofthe Aroostook Mental Health Center, for serving as the Co-Chairs of the study’s AdvisoryCommittee.Members of the Study Team and Advisory Committee (in alphabetical order)Carol CarothersDawn CookWesley DavidsonRonald DeprezLynne DubyWilliam FosterElsie Freeman, MD, MPHJohn GaleMeg HaskellJeffrey Holmstrom, DONeil Korsen, MDDavid LambertKevin LewisTom McAdamLisa MillerDavid Moltz, MDMary Jean Mork, LCSWNancy MorrisDavid Prescott, PhDRoderick Prior, MDNAMI MaineHealth Access NetworkAroostook Mental Health CenterCenter for Health Policy, University of New EnglandYouth & Family Service, Inc.Muskie School of Public ServiceMaine Department of Health and Human ServicesMuskie School of Public ServiceBangor Daily NewsAnthem BC/BS of Maine/University Health CareMaineHealthMuskie School of Public ServiceMaine Primary Care AssociationKennebec Behavioral HealthRepresentative, District 52Consultation Project, Maine Association of Psychiatric PhysiciansMaineHealthMaine Health AllianceAcadia HospitalMaineCareMost importantly, we are grateful for the generous support of the Maine Health AccessFoundation, which provided funding for this study and providing encouragement and advice. Dr.Wendy Wolf, President and CEO of the Foundation, and Barbara Leonard, Vice President forPrograms, provided insightful comments on report drafts and materials. Ms. Leonard, ProjectOfficer for this study, helped us to keep a steady eye on the goals of this study and engage allrelevant stakeholders.
Table of ContentsExecutive Summary . iBackground . 1Maine Barriers to Integration Study . 1Ongoing National and Maine Activities Related to Integration . 3Barriers to Integration Identified in the Environmental Scan . 4The View from Maine: The Stakeholder Interview Process. 8Methodology and Limitations . 9Overarching Themes . 10Defining Integrated Behavioral and Physical Health Services . 12Review of Integration Barriers and Solutions by Category of Respondents . 13Professional Associations and Advocacy Organizations . 14Barriers Identified by Professional Association and Advocacy Organization Respondents 14Recommendations to Enhance Integration by Professional Association and AdvocacyOrganization Respondents . 17Legislators and Other State Officials . 20Barriers Identified by Legislators and Other State Officials . 20Recommendations to Enhance Integration by Legislators and Other State Officials . 23Payers, Purchasers and Managed Care Organizations . 25Barriers Identified by Payer, Purchaser, and Managed Care Organization Respondents . 26Recommendations to Enhance Integration by Payer, Purchaser, and Managed CareOrganization Respondents . 28Maine Department of Health and Human Services . 31Barriers Identified by DHHS Respondents . 32Recommendations to Enhance Integration by DHHS Respondents . 34Practices and Providers Including MeHAF’s Year One Integration Initiative Grantees . 36Barriers Identified by Practice and Provider Respondents . 37Barriers Identified by Physical Health Provider Respondents . 37Barriers Identified by Behavioral Health Provider Respondents . 41Recommendations to Enhance Integration by Practice and Provider Respondents . 42Findings and Discussion . 44How Much Progress Have We Made? . 44Summary of the Major Barriers to Integration . 53Conclusions and Recommendations . 54Overarching Priority: Realign Maine’s Health Care System to Ensure Integration . 55Issues for Further Analysis . 59Next Steps . 61
Executive SummaryMaine Barriers to Integration StudyIntroductionThe Maine Health Access Foundation (MeHAF) has undertaken a long-term initiative topromote patient and family-centered care through the integration of behavioral and physicalhealth services in Maine. The foundation has funded several rounds of grants to primary care,behavioral health, and specialty providers to develop integrated services. To support this work,MeHAF commissioned this study to identify barriers to integration in Maine. In Phase One, weconducted an environmental scan, which included a literature review on the clinical, financial,administrative, and regulatory barriers to integration and a review of integration initiatives inMaine, other states, and Canada. In Phase Two, we interviewed representatives from Maine’sbusiness community, payers, purchasers, professional associations, state legislators, advocacyorganizations, state government, and provider organizations. The interviews provided a contextto understand the barriers to integration in Maine and develop recommendations to overcomethem. Our Final Report presents key findings from the study, recommendations for addressingbarriers, and next steps for moving forward. This study recognizes the need for integration ofbehavioral and physical health services in all settings. Although most discussions of integrationfocus on the development of behavioral health services in primary care settings, this studyacknowledges the challenges faced by individuals with chronic and/or severe behavioral healthproblems in obtaining vital physical and primary health care.Findings and DiscussionThis study examines lessons learned from the operation of integrated programs nationallyand in Maine. While these lessons support continued investment in integration, they alsohighlight the need for policy, regulatory, and reimbursement changes to sustain integratedservices and additional data on their impact on access, quality, and effectiveness. To furtherintegration, we must evaluate the outcomes of integrated programs, expand the range ofproviders participating in integrated care; enact state-specific policy, regulatory, andreimbursement changes to ensure sustainability of these services; and assist providers inenhancing their levels of integration through technical assistance and education. If successful,Executive Summaryi
access to integrated care for Maine residents with physical and behavioral health needs willimprove. Four themes emerged from our work: (1) integration enjoys strong support amongpolicymakers, providers, and consumers; (2) sustainability of integrated services remains asignificant unresolved problem; (3) there are no easy solutions for sustainability; and (4) data onthe impact of integration on access, quality, and effectiveness of care in Maine is needed tosupport change.Low payment rates and complex reimbursement policies are primary barriers to the longterm sustainability of integrated services. Although medication management and therapy servicesare generally covered by payers, reimbursement rules are complicated, applied inconsistentlyacross settings, and often do not match service delivery in primary care settings. Payers typicallydo not pay for care coordination and management, important elements of integrated care. Aspayers may believe they are adequately supporting integration by paying for direct services, wemust consider how we can use existing evidence to encourage needed change and what newevidence on the impact of integration on access, quality, and effectiveness is required?Several other issues emerged from our study. Since no one model is right for all providersand settings, integration is best viewed as a continuum, ranging from collaboration without colocation (e.g., collaborative referral relationships) to fully integrated co-located systems of care.Providers should be encouraged to assess their readiness for integration and to implementinitiatives appropriate to their state of readiness, delivery setting, and market. Providers shouldalso be encouraged, as practical, to move further along the continuum of integration.Additional barriers in Maine include complex and often conflicting licensure,credentialing, and scope of practice regulations and the policies of some payers that excludecertain qualified clinicians, such as marriage and family therapists, from reimbursement.Addressing these barriers involves adopting changes in these areas and reconciling conflicts tosupport integration at the provider level. Better dissemination of data on the impact of integrationinitiatives in Maine and the lessons learned from these initiatives would also be of value inaddressing these barriers. Greater technical assistance and educational resources would assistproviders of all disciplines in overcoming provider-level barriers as they develop their owninitiatives. An explicit knowledge resource on integration would support efforts to overcomebarriers by serving as a coordinated repository of knowledge of current and best practices oniiBarriers to Integration
integration and as an “honest broker” of knowledge in integration and policy discussions. Thisknowledge resource would link to, draw upon, and synthesize existing knowledge anddisseminate it widely to providers, policymakers, and payers to further the development ofintegrated care in Maine.RecommendationsAn overarching priority is to develop consensus for regulatory, policy, and reimbursementchanges necessary to support and advance integration in Maine. As part of this process, weshould seek to realign Maine’s health care system using the Institute of Medicine’s Six Aims(e.g., care is safe, effective, patient-centered, timely, efficient, and equitable) as a guide. At thesame time, it is important that we “level the integration playing field” by eliminating servicedelivery silos; paying consistently for integrated services regardless of setting or discipline ofproviders; and improving on and expanding integration by using the knowledge and skill sets ofproviders rather than focusing on licensure categories. We must avoid an incremental approachthat builds on a broken system and does not create fundamental change. Consistent with thispriority, we offer the following recommendations to promote integration in Maine: Address system-level barriers in Maine by reconciling conflicting regulations,reimbursement strategies, and policies; collect and disseminate data on the impact ofintegration initiatives; develop technical assistance and educational resources forproviders interested in integration; develop continuing education resources on integrationfor the health care workforce; and consider implications of expanded content onintegration for degree programs for physicians, physician assistants, nurse practitioners,advanced practice nurses, psychologists, social workers, nurses, and other disciplines. Develop and disseminate a consensus framework identifying the core elements ofintegrated care with which to educate policymakers, payers, and purchasers. Strengthen the role of the State Health Plan by incorporating stronger language related tointegration and including activities focused on advancing the state of integrated healthcare in subsequent revisions to the Plan; encourage MeHAF’s Integration InitiativePolicy Committee to provide input into the next round of revisions to the Plan; andcontinue financial support for depression and mental health questions and includeExecutive Summaryiii
questions on integrated care in the Maine CDC/DHHS Behavioral Risk FactorSurveillance System telephone questionnaire (funding is only available through 2010). Monitor the implementation of behavioral health in the medical home pilot project;encourage participants to achieve higher levels of integration; encourage consistentparticipation among all payers and purchasers in Maine; include specific questions onintegration in the planned evaluation of the pilot project and disseminate the results toadd to the evidence base; provide technical assistance and education to pilot sitesdeveloping integrated services; and understand the implications of language onapproaches to integration (e.g., the term “medical home” conveys a medically basedmodel of integration that does not encompass integrated initiatives in other settings). Ensure that issues related to integration are considered in discussions of payment reform.Next StepsTo begin the change process, the study team and Advisory Committee stronglyrecommend that the Environmental Scan, Final Report, and Executive Summary be widelydisseminated to payers, purchasers, the Maine Health Management Coalition, Quality Counts,the legislature, the Department of Health and Human Services, the Advisory Council on HealthSystems Development, MeHAF’s learning community, and other stakeholders. Thedissemination process should engage stakeholders in discussions to: develop consensus onintegration issues; achieve critical mass for initiating needed change; secure the commitment ofstakeholders to participate in the change process; identify resources stakeholders will commit tothe process; and identify recommendations for priority policy, regulatory, and reimbursementchanges. We further recommend that MeHAF’s Integration Initiative Policy Committee serve asthe vehicle to analyze the results of these discussions, identify consensus points acrossstakeholders, and establish priority action steps.ivBarriers to Integration
BackgroundPromoting patient and family-centered care is a long-term funding priority for the MaineHealth Access Foundation (MeHAF). From a patient’s perspective, our health care system lacksorganization, integration, and coordination and is difficult to navigate, particularly for uninsuredor low-income people. Consequently, MeHAF has sought to promote work that enhances patientparticipation and decision-making in their health care and that promotes better coordinationamong the different parts of our health care system. MeHAF has been particularly interested inimproving the integration of primary care and behavioral health services in Maine.MeHAF convened a steering committee to help it understand the nature and scope ofintegration in Maine and to establish a vision and goals for developing integration throughout theState. This effort resulted in the document, Integrated Health Care in Maine: Visions, Principlesand Values, and Goals and Objectives 1 , which is designed as a general guide for integration inMaine and for MeHAF’s grantmaking efforts in this area. The visioning process was followed bygrants to grassroots organizations to host discussion groups with Maine residents on whatpatient-centered care means to them. This effort was summarized in Maine Integrated HealthInitiative: Maine People Speak About Health Care Integration. 2 MeHAF has funded severalrounds of grants to providers to develop or enhance integration within their settings. MeHAFalso funded this study to identify barriers to integration in Maine and propose and prioritizepotential solutions to these barriers.Maine Barriers to Integration StudyDuring the first phase of the study, we completed a broad environmental scan, whichincluded an extensive literature review of the clinical, administrative, and financial barriers tointegration, an analysis of different approaches to and models of integration across diverse typesof providers, and a review of integration initiatives in Maine, other states, and Canada. Toprovide a local context for the environmental scan, we interviewed representatives of stakeholderorganizations funded by MeHAF under the first round of integration grants. We also conducted afocus group with administrators and board members of some of Maine’s Federally QualifiedHealth Centers, assembled by Kevin Lewis, Executive Director of the Maine Primary Care12Report available on the MeHAF web site: ttp://www.mehaf.org/pictures/integration vision.pdfReport available on the MeHAF web site: 2007.pdfMuskie School of Public Service1
Association. The results of these efforts inform the recommendations made at the end of thispaper and are summarized in more detail in the Maine Barriers to Integration Study:Environmental Scan which is available on the Maine Health Access Foundation web site(http://www.mehaf.org/).In phase two, we conducted interviews with a broad range of stakeholders in stategovernment, the business community, third party payers, purchasers, professional and tradeassociations, members of the state legislature, advocacy organizations, and providerorganizations. The goal of these interviews was to identify specific barriers to integration andsolicit recommendations for incentives and solutions to overcoming these barriers. The resultsare summarized in this report as are our findings and recommendations resulting from the overallscope of work for this study.The stakeholders we interviewed (including grantees from the
recommend that the Environmental Scan, Final Report, and Executive Summary be widely disseminated to payers, purchasers, the Maine Health Management Coalition, Quality Counts, the legislature, the Department of Health and Human Services, the Advisory Council on Health Systems Development, MeHAF’s learning community, and other stakeholders. The
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