Access, integration top priorities for adults with mental illness

Medicaid beneficiaries who receive care for mental health or substance abuse have greater physical health needs and higher overall costs than other beneficiaries, indicating the need for better integration of physical and behavioral health care under Medicaid, according to Providing Care to Medicaid Beneficiaries with Behavioral Health Conditions: Challenges for New York, a February 2011 report from the Medicaid Institute at United Hospital Fund in New York City.1

Barriers for adults with serious and persistent mental illness who are on Medicaid include shortages of housing and community supports and inadequate outreach and engagement efforts, says Michael B. Friedman, adjunct associate professor at Columbia University School of Social Work and former director of the Center for Policy, Advocacy, and Education of The Mental Health Association, both in New York City.

Most adults with mental illness who are covered by Medicaid don't have a long-term psychiatric disability, notes Mr. Friedman. "Integrated treatment for them can probably be provided in the context of primary health care," he says.

However, for people with long-term psychiatric disabilities, integrated services often need to be provided in the context of behavioral health programs, says Mr. Friedman, at least for those who have access to services and use them.

"Others either cannot get services they might benefit from, or reject them," he says. "For them, expansion of service capacity — especially housing and outreach — is critical."

Goal of increased access

There is disproportionate physical morbidity and premature death among individuals served in the public mental health system, says Charles Ingoglia, MSW, vice president of public policy at the National Council for Community Behavioral Healthcare in Washington, DC, primarily due to preventable medical conditions such as cardiovascular, pulmonary and infectious disease.

"Increasing access to primary healthcare for this population is one of the most important policy priorities," says Mr. Ingoglia.

The Patient Protection and Affordable Care Act (PPACA) solidifies federal support for the Substance Abuse and Mental Health Services Administration's primary care/behavioral health integration program, notes Mr. Ingoglia, and includes dedicated funding for the expansion of community health centers and the services that they provide, including behavioral health services.

The PPACA also contains a number of delivery system redesign projects, Mr. Ingoglia adds, including healthcare homes and Accountable Care Organizations, and behavioral health conditions are explicitly mentioned in both cases.

"Persons with serious mental illness are mandatory populations for the Medicaid health home state plan option," he says. "Community mental health organizations are listed as eligible medical home providers."

These models will test the ability of healthcare providers to work together to manage the overall healthcare expenditures for a defined population, says Mr. Ingoglia. "The prevalence data related to behavioral health conditions suggests that these efforts will fail, if they do not adequately involve the treatment of underlying behavioral health conditions," he adds.

The most costly Medicaid cases involve individuals with co-occurring serious physical and behavioral disorders, including both mental and substance use disorders, notes Mr. Friedman, and this population is often not connected with the mental health system.

"Almost everyone agrees that managed care for the high-cost cases, who are generally people with serious co-morbid conditions, is the way to go," he says. "This includes managing medication, as well as managing other forms of treatment."

The PPACA emphasizes integration of physical and behavioral health services via "medical homes" and "health homes," notes Mr. Friedman, but he is doubtful that medical homes will do much to improve service for people with serious and persistent mental disorders.

"They are fundamentally primary health care practices that will provide modest coordination with behavioral health care," he explains. "On the other hand, health homes are designed to be comprehensive managed care organizations. If New York is any example, they can and will be used specifically for the population of highest cost Medicaid cases."

For a couple of years, states will be able to establish health homes and get a substantial increase in the federal share of Medicaid, adds Mr. Friedman. "If it proves possible to engage those people who are the highest cost Medicaid cases before they develop acute disorders that require long inpatient stays, substantial cost savings should be possible," he says.

The big question, according to Mr. Friedman, is whether health homes will be successful in engaging the high-cost cases, which will require extensive outreach efforts rather than waiting for these individuals to come in for care on their own.

"Assertive community treatment teams have been effective in doing this, as have some case management programs," he says. "Whether a managed care entity will be able to do this remains to be seen."

Contact Mr. Friedman at (212) 851-2300 or and Mr. Ingoglia at (202) 684-7457 or


1. Patchias EM, Birnbaum M. Providing care to Medicaid beneficiaries with behavioral health conditions: Challenges for New York. February 2011: Medicaid Institute at United Hospital Fund, New York, NY.