This is the fourth in an ongoing series of blog posts highlighting states across the US that support integrated care initiatives. Click here for the third, second and first posts.
I get it. I live in Nirvana. I get to live in one of the most beautiful places in Oregon that just happens to be one of the hottest tourist spots around. Skiing, biking, rafting, beaches, fantastic pinot noir and more craft beer per capita than any other state in America. Life is different in Oregon, especially in Bend. We have that "pioneeer spirit” that drives innovation, independence and even weirdness. Oregon is also home to the largest Medicaid experiment in the country—Coordinated Care Organizations (CCOs)—and at the heart of that experiment is a dedication to integrated care.
The CCO journey started in 2009 in Central Oregon and as luck would have it, that’s my backyard. Anyone who knows me quickly realizes that I have a tenacious spirit. Some would liken it to a honey badger with a beehive—I really don’t care how often I get stung as long as I get results. That tenacity paid off for our region with an early commitment to integrating behavioral health in primary care as part of our Medicaid innovation. It wasn’t a tough argument to make. At least 70% of all behavioral health visits were already happening in primary care, and when people were being referred to mental heath providers for follow up, only about 10% of them actually followed through. These statistics are common everywhere, so logical people reach the logical conclusion that you provide care where people present, right?
I was also naïve. I had the data, the providers, the evidence based practices—but what I didn’t have were regulations on my side. So, I did what most folks do at this point—I created a work around!
Work arounds are great. They allow you to try out new practices, see if they work before you change the big things, and sneak your way about budgetary restraints to innovate. However, they are also dangerous. When we hired our first psychologist and placed him in a primary care clinic in rural Oregon, we had not defined how he would bill and be paid outside of a reliance on "Health and Behavior Codes” and the largesse of my employer, St Charles Health System. People were excited! Finally! They would have access to a psychologist in a community that had so few options for behavioral health; even Lucy van Pelt would have been an improvement! It was glorious….
Then, reality set in. Many payers rejected the H&B codes or set arbitrary limits on their use. Multiple co-pays ensued as folks struggled to figure out how to bill things. And then…the dreaded Regulatory Dragon reared its head and snarled fire, insisting that "mental health services could not be provided in primary care.” It all came down to ancient rules around who could bill for what services in what settings. In other words, it was all about the money.
For those of you who are unfamiliar with CCOs, I’ll give you a quick overview. Prior to the Affordable Care Act implementation, as part of Oregon’s healthcare reform package, they proposed an experiment to remove many of the restrictions on how Medicaid funds can be accounted for and create CCOs, which managed a global budget for the provision of care to a given population. There are 16 CCOs in Oregon that have been operational since 2013. They have to meet their contractual obligations to a Transformation Plan that includes a plan for integrating care—physical, behavioral and dental—and they must show progress on Quality Incentive Metrics each year in order to receive their full allocation of funds. Most importantly, they must show a decrease in the amount of funds needed to treat the Medicaid population overall—and do this over time for years, with an overall reduction equal to the investment ($11 billion) when the project is over. Suffice it to say, it’s complicated.
Most CCOs in Oregon didn’t have the built in expertise to immediately deal with behavioral health, much less integrated care. Integration was a great idea, but mental health and addiction services had always been the purview of the community mental health system. Their byzantine requirements to code and bill for mental health visits required a special "Certificate of Approval” even for licensed folks. Some CCOs found ways around these requirements, but many did not. That’s where Senate Bill 832 came in. If we changed the regulations, we could remove the barriers to providing integrated care. And so it began….
"School House Rocks” taught us that bills aspiring to be laws must pass through committees in a bicameral legislature then make their way up the long steps during lively debate to eventually become laws. If only it was that simple. The process for bills is far more complicated than that, starting long before the legislative session begins. I had the crazy idea that if we could define the practice of integrated primary care in statute, then we could promulgate rules to support that practice and begin to unwind decades of policy created to keep the provision of mental health services protected from the clawing hands of those who wanted their budget. Who could argue with that! Did I mention I was naïve?
Fortunately, I have friends. Some of my friends like C.J Peek and Ben Miller provided invaluable editorial guidance, grounded in the Agency for Health Research and Quality’s work on defining integrated care. Others are the great folks at CCO Oregon who sponsor the Integrated Behavioral Health Alliance of Oregon, a collection of the movers and shakers in Oregon’s integrated care programs, who served as the "think tank” behind what barriers needed to be removed to facilitate the sustainable practice of integrated care. While not formally able to sponsor the bill itself, their real world experience in a variety of CCO models was invaluable to creating model legislation.
I also have friends where it counts—in the Capitol itself. The path to making good legislation starts with the people who live in the building—Legislators, their staff, and the Lobby. Bills that become laws are part of the intricate dance between competing interests that often have little to do with the substance of a bill itself. In large part, that’s by design, creating a space where large interests don’t always get their way and small interests can find a path. The most import thing about the Capitol in any state is always to remember that your ethics define you. Always speak the truth, and if you make a mistake, own it and clean it up. Never surprise a Legislator unless you absolutely have to. Do favors for people whenever you can—and if you can’t do it, find someone who can (as long as it’s legal?) Be nice to staff—always—because they control your access to everything. And, don’t just come into the building for your own issues. Be there for those others care about—because you never know when you’ll need them.
The true tale of SB 832 is best told over a vodka martini, dirty and bruised, with blue cheese olives. Given that isn’t possible in a blog post, I’ll hit the highlights:
- Run concept for bill past most influential Legislator you know who gets the issue and can move the bill. In my case, Senator Laurie Monnes-Anderson, Chair of Senate Healthcare. Get a note to draft a bill!
- Work closely with Legislative Counsel on language for a concept that is difficult to explain and even more difficult to put into existing law. Negotiate on that language with a large group of your best friends for months.
- Get your "final” Legislative Concept into your Chief Sponsor before the deadline so she doesn’t have to use a "priority bill” slot! Now, go find your friends and convince them to sign on as co-Sponsors. Remember to get plenty of R’s and D’s on both sides of the building! Trade favors with staffers to get sponsors for other bills—always good to build up goodwill!
- Once your Legislative Concept comes out, be prepared for
o Monday Morning Quarterbacks
o Fear Mongers who are convinced you want their money
o Supporters who run away at the first sign of controversy
o Detractors who completely misread your concept and are convinced that PEOPLE WILL DIE IF YOU DO THIS
o Closet Grammarians
- Schedule your first hearing! Beg to be assigned to your Chief Sponsor’s committee, and scramble when you aren’t!
o Bring those friends who helped you get here to tell the story
o Be prepared to find out who really doesn’t like this idea and didn’t have the courage to tell you in advance
- Get schooled in "back room politics”
o Be persistent and flexible
o Open your mind to new ideas, even if you don’t agree with them
o Embrace sausage making!
o Compromise is the art of the deal
- WAIT MORE
- When your bill finally starts to move, stay close and shepard it so it doesn’t get lost in the bowels of parliamentary procedure and legislative process
o Don’t be afraid to call those friends you’ve been helping along the way. You never know when they can help you unless you ask!
- Don’t celebrate until the Governor signs your bill (don’t want to jinx it!)
At the end of the process, SB 832 did more than just define integrated care in Oregon. The new law also defines "Behavioral Health Homes” which will support the provision of primary care in community behavioral health centers, creating access for care to some of our most severely impacted people. There are now definitions for "Behavioral Health Clinicians” that include residents and interns, creating paths for them to be paid for their services and support workforce development. Most importantly, however, the new law promulgates rules that will define how person centered primary care homes implement integrated care in a standardized, evidence-based way, and create outcomes that will support sustainability.
It’s always better to slay the Regulatory Dragon than to find ways to bypass his kingdom. In my little corner of the world, that’s how my friends and I moved integrated care forward. Sure, there will be skirmishes and turf wars as we negotiate and implement these new rules, but we won the war and defined integrated care in statute.
Yup—I get it. I live in Nirvana—and its spelled OREGON.
Robin Henderson, PsyD, Chief Behavioral Health Officer and Vice President of Strategic Integration at St. Charles Health System, is responsible for the strategic direction, operations, and integration of behavioral health services across the health system and throughout primary care, and she oversees the development and implementation of the health system's strategic plan and system portfolio. She also manages the health system's advocacy efforts and its relationships with government programs and community partners, including their strategic partnership with the Institute for Healthcare Improvement. She retains an active Oregon license as a psychologist, and is past president of the Oregon Psychological Association.