High Risk, High Reward

By Monica E. Oss, Chief Executive Officer, OPEN MINDS

More than one in three non-elderly adults enrolled in Medicaid have a mental illness (35%), including 10% with a serious mental illness, according to a recent report, 5 Key Facts About Medicaid Coverage For Adults With Mental Illness. These rates are higher than those among adults with private insurance or uninsured adults.

The data is interesting. Among Medicaid adults, mental illness is most prevalent among White adults, rural or small metro residents, those aged 26-34, and females. And those rates vary by state—from 22% in New Jersey to 51% in Iowa. Similarly, the percentage of adult Medicaid enrollees with a serious mental illness ranges from 4% in Mississippi to 22% in Wyoming and Missouri.

Not surprisingly, Medicaid enrollees with a mental illness have higher rates of substance use disorders and chronic health problems than those without a mental health diagnosis. Approximately two-thirds of adult enrollees with any mental illness have at least one other chronic condition—twice the rate of those without a diagnosed mental illness.

Enrollees with serious mental illness have the highest rates of chronic conditions, with 76% having at least one chronic condition. Of those chronic conditions (defined as lasting at least a year and requiring ongoing medical care), the most common chronic condition among Medicaid enrollees with mental illness is substance use disorder. One in four enrollees diagnosed with any mental illness also has a diagnosed substance use disorder, and about 40% of those diagnosed with serious mental illness (SMI) do, compared to 5% of enrollees without a mental health diagnosis.

This translates into higher spending—spending for Medicaid beneficiaries with a mental illness is twice that of those without—about $14,000 per year—compared to roughly $7,000 for those without a mental health diagnosis. Spending is highest among adults diagnosed with a serious mental illness, at approximately $21,000 per enrollee per year, which is three times higher than the annual spending for those without a mental illness. Medicaid spending for adults with any mental illness accounts for one-third of the total Medicaid spending for the non-elderly, non-dual eligible adult population.

These are the factors—both clinical and financial—that are driving the interest in whole person care models and integrated delivery systems among health plans. The question for provider organization executives is two-fold: how to negotiate “total cost of care” contracts with health plans, and how to manage costs under those contracts. 

We got a look at how one organization does just that in the session, Analytics To Support Whole Person Care & Optimize Reimbursement Rates: The Copa Health Case Study at The 2024 OPEN MINDS Whole Person Care Summit. Dr. Jacqueline Webster, Assistant Director of Population Health, and Derrick Baker, Quality Improvement Manager, for Copa Health, shared their approach—and the analytics and population health management tools they used to optimize their returns under performance-based contracts.

Copa Health, an $82 million non-profit, has been providing services since 1957. It currently supports approximately 14,000 people with complex medical and support needs in two Arizona counties and Utah. Its services include 18 homes for individuals with serious mental illness, 19 homes for individuals with I/DD, employment-related services, and seven integrated health clinics with a focus on whole person care.

Copa Health holds multiple value-based contracts with health plans, including Mercy Care and UnitedHealthcare. These agreements are centered on Copa’s integrated outpatient clinics and encompasses a broad range of services—including primary care, behavioral health, permanent housing, and supported employment. The contracts link financial incentives to improvements in clinical outcomes and cost containment, with performance metrics such as diabetes screening rates, follow-up after behavioral health hospitalizations, medication adherence, and reductions in emergency department utilization. In 2023, Mercy Care expanded its partnership with Copa through a new value-based agreement developed in collaboration with Copa’s Accountable Care Organization (ACO) affiliates, Affiliated Network Providers.

To better manage the health outcomes and the costs of consumers in their programs, Copa Health executives presented two examples. The first was the management of A1C levels in their consumer population. The other was the creation of their “high-risk” registry (HRR) program.

To manage A1C levels, Copa’s approach starts with analysis of consumer data–identifying consumers in need of testing or other interventions. Designated staff receive automated email messages with lists of members with upcoming appointments who also need A1C monitoring—information that is shared in the morning huddle of clinical team members. Following that meeting, outreach to affected consumers happens. When tests are conducted and the lab work is completed, that data is aggregated by A1C status and location for additional outreach.

Copa’s HRR program uses aggregate consumer data (high emergency department or inpatient utilization, Health Information Exchange (HIE) alerts, discharge records, current level of care, admissions, discharges, transfers, etc.) to identify members who may benefit from individual coordinated care interventions. Clinical teams then review these recommendations, adding nuance and context that the data alone can’t provide. Once members are placed on the registry, they are enrolled in a coordinated care management process that brings together primary care, psychiatry, nursing, and case management teams. These teams meet regularly to understand the drivers of high utilization and implement proactive, personalized interventions.

“We have integrated care coordinators and care managers who work specifically with this population to determine strategies to help reduce utilization,” explained Dr. Webster. “Our care managers then continue monitoring from there.”

Copa’s care management approach improves consumer health status—and is important in payer negotiations. “You can use the savings that you’re having from someone not going to the emergency department, document that data, and use it to identify case studies,” Dr. Webster said. “We’ve had a member who went from 60 ER visits to 14 over six months. Make sure you’re using clear data reports to show those cost savings from the initiatives that you’re doing, and then really emphasize the improved health outcomes and increased screenings.”

The Copa Health leadership team reflected on what they would do differently if starting today on the path toward value-based, integrated care. Their first recommendation was to invest in continuous staff training, particularly in areas essential to data fluency and value-based care operations. Engaging team members from across departments in the development of workflows helps draw on institutional expertise and build ownership. “We want to retrain if anything changed in their workflows,” explained Mr. Baker. “We found out where we could tweak workflows to integrate data to guide next steps.”

Their second recommendation was start “now”, with the with the tools already available—using existing resources to gather data, track key metrics, and build a foundation for performance management. Large-scale investments in new technology and infrastructure, they noted, can follow.

“Managing care to reduce emergency room visits and generate cost savings while producing better outcomes can be done with tools as simple as spreadsheets or with integrated data and analytics suites. The tools matter less than creating the structures and the workflows and documenting the results… If a member has missed multiple telehealth appointments, staff can use this information to tailor the intervention,” Dr. Webster said. “And if you’re doing these initiatives that focus on the clinical outcomes and the no-show rates and the A1C screenings, you will reduce hospitalizations, and that is creating cost savings.”