Medical News: What is your long-term vision for Medicaid in Kentucky?

Anthony Zipple: Today, Medicaid is the single largest payer for behavioral health services both in Kentucky and the United States. I do not expect that this will change anytime in the near future. In fact, my expectation is that the importance of Medicaid as a payer for behavioral health services will expand rather than contract.

This means that Medicaid, both nationally and in Kentucky, needs to develop a clear vision for the value and structure of behavioral health services. I believe that the single greatest opportunity for Medicaid is achieving true integration of behavioral health services and other medical services.

We now have decades of evidence that providing better and more assertive, evidence-based behavioral health services simultaneously improves outcomes, increases client satisfaction, and decreases the total Medicaid spend.

In spite of 40 years of research that documents the importance of behavioral health in healthcare and population health, Medical systems in the United States have been slow to organize in a way that recognizes and maximizes this reality. I would like to see a system in which Medicaid takes a far stronger leadership role leveraging the opportunities presented by behavioral health services and pushes the entire U.S. healthcare system to fully incorporate the importance and potential of great behavioral health services.

MN: Has the expansion of Medicaid and the implementation of the Affordable Care Act helped or hurt your ability to provide care to the Medicaid population in Kentucky?

AZ: The Affordable Care Act (ACA) and expansion of Medicaid in Kentucky has, on balance, been a very positive development. More than 450,000 Kentucky citizens who had limited access to behavioral health and medical services prior to the ACA and Medicaid expansion now have greatly improved access to services that have the potential to transform their lives.

Most of these individuals have limited incomes and prior to the ACA and Medicaid expansion struggled to afford even the most basic care that middle-America takes for granted. In a country as affluent and compassionate as the United States, this was a shocking and painful everyday reality.

Medicaid expansion along with the ACA has also expanded the range of available behavioral health services. For example, substance use treatment services are now a required part of state Medicaid plans, a welcome addition in
Kentucky.

We have a well-documented crisis with heroin and other opiates in Kentucky, and today we now have access to evidence based treatment at provider organizations like Centerstone which means patients have far greater hope for recovery and a good life. This kind of access changes everything for our friends, neighbors and relatives who previously lacked access to critical services.

We also know that simply providing access to care is not enough. Creating a payment mechanism for services does not guarantee that everyone has exactly the healthcare that they need and deserve but it is a foundational step in the process of reinventing and providing an enhanced system of healthcare in Kentucky. The ACA and Medicaid expansion has provided a great foundation on which we can build.

MN: If you could run a pilot program within the Medicaid space what would you do to significantly move the needle and improve overall health outcomes for this population?

AZ: Nationally, as well as in Kentucky, we have not taken full advantage of the promise offered by behavioral health services and their recognition as a central component of overall healthcare, particularly for individuals with complex behavioral health conditions and co-occurring medical illnesses.

If I could run a single pilot in Kentucky to improve the health of a large group of those under-served in our communities, it would be to aggressively develop behavioral health provider based health homes for specialized populations who present high cost and high risk. These would include for example, individuals with serious and persistent mental illness, individuals with significant substance use and addictions problems, and children with complex emotional disorders.

We know that individuals with these complex conditions consume high levels of behavioral health service as well as high levels of medical services. We know that we are not serving them well. People with serious mental illness die 25 years earlier than the general population, most often from cardiac and metabolic conditions that we think of as preventable.

We know that providing appropriate and effective behavioral health services improves clinical outcomes and extends the lives of these individuals. And we also know that providing evidence based behavioral health interventions reduces medical costs and the overall Medicaid spend. These are facts that have been established in states like Arizona, Indiana and Tennessee.

Better outcomes, better quality of care, better quality of life, lower mortality rates and lower overall cost is a compelling argument for assertive development of behavioral health specific health homes for specialized populations. I have watched other states develop systems of care that achieve these successes and I know that we could do it here if we commit to making it happen.

MN: What steps would you like to see Kentucky and federal officials take to improve the provider environment, specifically as it relates to serving the Medicaid population?

AZ: The Medicaid system is still too focused on traditional medical intervention and not focused enough on community intervention and managing population health variables. We know that clinical intervention accounts for only about 20 percent of the variance in health outcomes and yet that is where almost the entire $500 billion annual Medicaid budget is spent. Individual circumstances (including housing status, poverty, and educational status) and as well as individual behaviors (including exercise, nutrition, and social supports) account for at least twice as much of the variance in health outcomes and Medicaid spends almost nothing on addressing these factors.

On one level, this is not a surprise. Medicaid is structured as a medical insurance program focused on traditional fee for service reimbursement for traditional medical illnesses. As such, it has great difficulty responding to behavioral and circumstantial factors that may be more important to health outcomes and the medical interventions themselves.

The bright future for state as well as federal Medicaid programs is developing provider contract and reimbursement structures that reward providers for population health interventions that improve outcomes, but these may not look like traditional medical intervention.

This is easy to say but hard to do. It will require revisions to medical training, a radical shift from fee for service reimbursement to population based contract structures, and the ability to think of patients as whole people rather than as a list of conditions for which we can bill. Medicaid is in the unique position to be both a thought leader and a contract driver in this essential but challenging evolution.