Medicaid coverage of physical, behavioral health together does not improve access, care

Health care systems in the United States have gradually embraced the concept that mental health should be treated on par with physical health, especially in light of increased rates of anxiety and depression during and after the COVID-19 pandemic.

To improve access to mental health treatment, many Medicaid programs have required their managed care organizations to pay for behavioral health and physical health together. That's in contrast to the traditional approach in which behavioral health, including treatment for substance use disorders, was "carved out" from typical health care coverage—forcing patients to get coverage through a totally different insurance plan.

The new approach, known as integrated managed care organizations, was presumed to lead to better access and outcomes for patients.

However, a new study led by Oregon Health & Science University reveals that the integration of behavioral and physical health did not lead to significant changes in access or quality of health services in the state of Washington.

"There was a hope that this would be a significant catalyst," said lead author John McConnell, Ph.D., director of the OHSU Center for Health Systems Effectiveness. "The idea was that integrating care within managed care organizations would drive positive changes at the clinical level, and that didn't really happen—at least not yet."

Published today in JAMA Health Forum, the study concludes that the administrative change may be necessary but insufficient on its own to improve access, quality and overall health outcomes for patients.

To achieve those outcomes, McConnell said it may require new training and incentives, including shifting from traditional fee-for-service payment models—where providers are paid for every medical visit—to alternatives such as those that pay providers for a set number of patients covered by the practice overall.

Researchers studied changes in Washington state, which has been a pioneer in promoting integrated care models to improve mental health treatment.

The new study assessed claims-based measures, such as mental health visits; health outcomes, such as reported incidents of self-harm; and general quality of life, such as rates of arrests, employment and homelessness among 1.4 million patients covered by Medicaid in Washington state. The analysis tracked a staggered rollout of financial integration across Washington's 39 counties between 2014 and 2019.

"The surprising result was that nothing really changed," McConnell said.

Although researchers weren't able to discern statistically significant improvements in access or outcomes for patients across the Evergreen State, McConnell noted that financial integration didn't make matters worse either. That's important, he said.

"It probably simplified things," he said.

In addition to McConnell, co-authors include Sara Edelstein, M.P.P., Jennifer Hall, M.P.H., Anna Levy, M.P.H., Maria Danna, M.A., Deborah Cohen, Ph.D., Stephan Lindner, Ph.D., and Jane Zhu, M.D., of OHSU; and Jürgen Unützer, M.D., M.P.H., of the University of Washington.