Integration of Mental Health into Primary Care: Novel Managed Care Model

A novel managed care model in Minnesota is showing the feasibility and benefits of integrating behavioral and mental health care, along with social and economic determinants of health, into primary care for some of the state’s most vulnerable citizens. 

Hennepin Health is an integrated Medicaid accountable care organization (ACO) that began in 2012 as a demonstration project under the Affordable Care Act to provide care for the early Medicaid expansion population (ie, childless adults living at or below 75% of the poverty line). Partnering with a network of providers affiliated with Hennepin County, including the county’s Human Services and Public Health Department, Hennepin Healthcare (a local teaching hospital), and Northpoint Health & Wellness Center (a federally qualified health center), Hennepin Health ACO employs a novel reimbursement structure to cover the myriad of services needed to address the complex array of needs affecting the health of their members—chronic diseases, mental health and/or substance abuse issues, homelessness, and poverty.

With state funding that allots a capitation amount per enrollee, Hennepin Health ACO created an infrastructure to provide direct care for its members through a network of provider partners. Provider services are reimbursed via the traditional fee-for-service payment structure, but provider partners also enter into a risk-sharing agreement with Hennepin Health that incentivize providers via value-based care payments to fulfill the mandate of managed care to improve outcomes while reducing costs. 

“I think this is what makes our model unique,” said Abdirahman Abdi, chief financial officer, Hennepin Health, Minneapolis, MN. “We have created an infrastructure to provide direct care, we pay for those services, and any savings we are able to generate are shared with our partners as a direct payment or reinvestment in programs to improve outcomes for services we provide to members.”

Early results show Medicaid members covered under Hennepin Health relied less on acute care and more on primary care, with a 9.1% decrease in emergency visits between 2012 and 2013 (with no change in hospital admissions) and 3.3% increase in outpatient visits.^1,2 

When comparing health care utilization between Hennepin Health and other Medicaid managed care plans in the same area from 2012 to 2014, mixed results were found with the overall use of primary care among Hennepin Health members slightly higher than other managed care plans but emergency room visits were also higher with no differences in hospitalizations.³ When looking at changes in quality of life, another recent study4 found an increase in quality of life for Hennepin Health members with multiple comorbidities, particularly those with physical conditions that overlapped with behavioral health conditions.

After nearly 9 years, the program continues to grow and expand its patient population and network providers. In 2014, the plan had an enrollment of 9054 members (or about 25% of all county Medicaid expansion beneficiaries).¹ 

Of the current 32,000 members enrolled in the county’s Medicaid programs, 30,000 are enrolled in the Hennepin Health ACO, according to Mr Abdi. In addition, he said that Hennepin Health has added two new area providers, Fairview Health Network and North Memorial Health, to help cover services needed for the significant behavioral health needs of its members.

Hennepin Health Access: Example of Integrating Behavioral Health Into Primary Care  

Among the network of community clinics aligned with Hennepin Health ACO is Hennepin Health Access (HHA), a Hennepin Healthcare clinic aimed at integrating behavioral and mental health into primary care to better engage patients in their traditional primary care to improve outcomes. 

Using a team approach that includes a psychologist, chemical dependency counselor, community health worker, nurse clinical coordinator, social worker, and medical providers, patients seen at the clinic receive comprehensive assessment of and management strategies for their psychosocial and physical health needs. 

Early results suggest that this approach may be working to both increase patient engagement in utilization of primary care services and decrease utilization of higher-cost services in a highly vulnerable patient population. A 2017 study⁵ that examined changes in health care utilization (team-based primary care and utilization of higher-cost services) among 222 patients seen at the HHA clinic over 12 months, found an increased utilization of primary care services and a significant decreased average utilization of higher-cost services (psychiatric inpatient care, psychiatric emergency department, urgent care, and medical emergency department care). A nonsignificant trend was also seen for decreased medical inpatient care. Most of these patients were men younger than 50 years, homeless (78%), mentally ill (75%), and chemically dependent (68%).

The cost savings of this team-based primary care approach was reported to occur after at least one encounter in the HHA clinic, with total per member per month costs decreasing 36.4%. 

For A. Katherine Hust, MD, MPH, medical director of the HHA clinic, the biggest advantage of integrating behavioral health into primary care is that it decreases stigma. “By integrating that support into the same site as primary care, we can remove some of that stigma and help patients to feel better about their mental health before connecting to additional resources,” she said, adding that the clinic is designed for easy access and accommodates walk-in patients that can help overcome some of the barriers for accessing mental health care.

Cameron C Weaver, PhD, LP, a senior psychologist who sees patients at HHA, underscored that patients appreciate having their care less fragmented across multiple clinics and systems and, for many, addressing their physical and mental health concerns from a multidimensional approach can lead to improvement without the need for more intensive courses of psychotherapy.

Likening the mental health services delivered at a clinic like HHA to a ladder, Dr Weaver said that one of his main jobs is to determine on which rung of the ladder a patient is on—on the top rung are patients who require inpatient psychiatric care, on the middle rung are those who need hospital-based outpatient programs and care, and on the lower rung are those treated by Dr Weaver in the primary care setting using a brief psychotherapy model. 

About 20% of his time is spent as a consultant for providers and other team members, which, he said is a key advantage of integrating behavioral health into the primary care setting as it gives providers confidence in addressing and treating mental health issues.  

Another benefit, according to Dr Hust, is that team members know what resources are covered and available to their patients. “We gain efficiencies because our patients have the same payer, so our whole team knows what resources they have because of their insurance,” she said. “That level of familiarity and knowledge of what a patient may be able to access outside the walls of the clinic is huge for being able to make positive changes particularly around social needs.” 

References:

1. Hostetter M, Klein S, McCarthy D. Hennepin Health: a care delivery paradigm for new Medicaid beneficiaries. The Commonwealth Fund. October 7, 2016. Accessed June 8, 2021. https://www.commonwealthfund.org/publications/case-study/2016/oct/hennepin-health-care-delivery-paradigm-new-medicaid-beneficiaries
2. Sandberg SF, Erikson C, Owen R, et al. Hennepin Health: a safety-net accountable care organization for the expanded Medicaid population. Health Aff. 2014. Nov;33(11):1975-1984.doi:10.1377/hlthaff.2014.0648
3. Vickery KD, Shippee ND, Menk J, et al. Integrated, accountable care for Medicaid expansion enrollees: a comparative evaluation of Hennepin Health. Medical Care Research Rev. 2020;77(1):46-59. doi: doi:10.1177/1077558718769481
4. Vickery KD, Shippee ND, Guzman-Corrales LM, et al. Changes in quality of life among enrollees in Hennepin Health: a  Medicaid expansion ACO. Medical Care Research Rev. 2020;77(1):60-73. doi:10.1177/1077558718769457
5. Hust K, Wippler M. Hennepin Health access clinic: payer-provider partnerships addressing psychosocial barriers to primary care. Poster presented at: Society of General Internal Medicine Annual Meeting; April 2017; Washington DC.