Finding The Right Combination For Managing Serious Mental Illnesses

Earlier this year, Centene’s Chief Operating Officer of Behavioral Health, Indira Pahari, discussed how 10% of their population uses 70% of the resources, in her keynote presentation, Improving Access & Collaboration For Complex Consumer Needs: Centene’s Approach To Integrated Care, at The 2022 OPEN MINDS Performance Management Institute. Her observation was that for the most part, this high-risk population is largely consumers with mental illnesses who are disconnected from the health care system.

The question for executives of health and human service organizations is what works for improving the health of this consumer group—and reducing their unnecessary use of expensive acute care services? We got a briefing on a model that works from Dr. Pahari’s colleague, Carole Matyas, vice president operations, at Sunshine Health. Since 2017, Sunshine Health has been operating a full-service Florida plan for individuals living with serious mental illnesses (SMI) (75% adults and 25% children). The state has expectations of both decreases in inpatient utilization and HEDIS score improvement—in addition to a requirement that 50% of reimbursement is some type of value-based contracting.

At the 2021 OPEN MINDS Executive Leadership Retreat, Ms. Matyas presented the Sunshine Health three-prong approach in her keynote presentation, “Innovative Programs That Demonstrate Positive Outcomes for The SMI Population.” The three core programs that Sunshine Health is deploying to address the needs of consumers with SMI includes behavioral health homes, a long-acting injectable (LAI) program, and a high-risk member engagement program. The results of these initiatives are impressive.

The behavioral health home model—The behavioral health home model is based on value-based contracts with community mental health centers (CMHCs). The CMHCs are given a per member monthly payment to fund both the behavioral health care coordination and the primary care services delivered in the same location. And incentives for the provider organizations are based on the primary care and behavioral health HEDIS measures, with a focus on gaps in care. Ms. Matyas is a strong advocate for integrated care. “You cannot make progress addressing all the needs of vulnerable populations if you are treating them in silos. It’s complex and hard to figure out, especially when you consider the dynamics at state and county levels, and in rural versus urban systems.”

The high-risk member engagement program—Sunshine Health’s program to engage high-risk members focuses on field visits to engage the member at home, provider offices, the hospital, or a community setting. This includes a process for rapid interventions including follow-up after hospital admissions, rounds with primary care professionals, and collaboration on social determinants. The approach includes providing mobile devices following an inpatient stay for consumers to connect with therapy services virtually, as well as stipends to cover costs of securing stable housing and other social needs. The resulting drop in member use of emergency room and inpatient services are impressive.

The long acting injectable medication program—Sunshine Health has also instituted a program to increase the use of LAIs by consumers with an SMI. The program has eliminated prior authorization requirements; promotes LAI starts while consumers are in the hospital; assigns case managers to coordinate injection appointments; and has built a pharmacy team with concierge services. The goal is a 25% increase in the use of LAIs. According to Ms. Matyas, “Once consumers with schizophrenia are stabilized with an LAI, then you can speak with them about things like solving their homelessness, treating their diabetes and hypertension, and working on a recovery model rather than a maintenance one. You also begin to see improved outcomes like reduced hospitalizations and emergency services.” The results show an overall increase of 1% in pharmacy spending with a 10.2% decrease in medical spending. Ms. Matyas explained, “While pharmacy and medical spending may increase on the front end, once engaged and stabilized, use of services eventually decreases substantially from changes in lifestyle and living environments, like achieving housing stability, having stronger peer networks, and only needing behavioral health services on a periodic basis.”

Underlying all of these programs is the financial alignment of Sunshine Health and their preferred provider organizations participating in these focused services. The behavioral health homes include both a per member per month (PMPM) payment and incentives on performance. In the consumer engagement program, participating provider organizations receive bonus payments based on HEDIS measures including seven-day follow up from hospital medication adherence, and 30-day hospital readmissions.

When asked about what was most important to her team in selecting provider partners, Ms. Matyas responded, “A collaborative relationship and performance data.” She spoke to the need for provider organization partners that understand the health plan challenges, are willing to share ideas; and volunteer for pilot programs. On the performance data front, she said that many of the provider organizations they value are those who proactively measure performance—from the consumer perspective and the health plan perspective—and share that data with the Sunshine Health team.

In a health care landscape with increasing price and cost sensitivity at all levels; a need for financial alignment around value; and more ownership of service delivery capacity by managed care organizations, executives of specialty and primary care organizations need a strategy to not only maintain their market share with high-risk, high-needs consumers, but to expand services for that population. That will be the sustainability challenge of the next year.