Connecting physical and behavioral health care is a big step for NC

Mandy Cohen, secretary of the NC Department of Health and Human Services, warned lawmakers in October that without a budget by mid-November, Medicaid transformation would be delayed.
Mandy Cohen, secretary of the NC Department of Health and Human Services, warned lawmakers in October that without a budget by mid-November, Medicaid transformation would be delayed.

At the NC Department of Health and Human Services, we know that focusing on the whole person to help him or her be healthier is a critical part of our mission. But until recently, we didn’t have all the tools we needed to break down the barriers separating our physical and behavioral health care systems so we could deliver on that mission.

Last month, the federal government approved changes that the General Assembly mandated for our Medicaid program. As we move from a system that primarily pays fee-for-service and is managed by the state to one run by managed care organizations, these changes give us powerful tools to make our new system more innovative, including the integration of physical and behavioral health for the two million North Carolinians enrolled in the Medicaid program.

This is a big win for North Carolinians. Like most states, behavioral health has traditionally been treated as separate from the broader health care system. That has often meant behavioral health clinicians working in different facilities than primary care doctors, with limited coordination between the two. On the financial side, including NC Medicaid, behavioral health services are paid for by one entity, while primary care is paid for by another. To people who receive treatment, it can be confusing.

Research shows us that behavioral health is intimately linked with physical health – and that both are heavily influenced by factors that seem on their surface to be unrelated. Many chronic diseases, including diabetes and heart disease, can be worsened by behavioral health conditions like depression or substance use disorders. This has been particularly apparent in the opioid crisis, with the use of injection drugs creating national epidemics of hepatitis C and other infectious diseases. With federal approval of our changes, we can begin to build a health system that acknowledges these connections and helps North Carolinians access physical and behavioral health services seamlessly.

In designing our plan around whole person health, we have benefited from the feedback and collaboration of many stakeholders, including legislators, managed care organizations, clinicians, and people in our Medicaid program. We’ve also learned from best practices in other states while crafting an innovative program that makes sense for North Carolina.

Beginning in 2019, North Carolina will enroll most Medicaid beneficiaries, including those with lower-intensity behavioral health needs, in “Standard Plans” to access physical health services, behavioral health services, long-term services and supports and pharmacy benefits through one insurance plan. Starting in 2021, people with certain higher intensity behavioral health needs, intellectual/developmental disability (I/DD) diagnoses or traumatic brain injury (TBI) needs, will be enrolled in “Tailored Plans,” specialized managed care plans with additional resources and expertise to meet complex needs.

While other states including Arizona, Florida, and New York have created similar specialty behavioral health plans, North Carolina will be among the first to implement fully integrated managed care plans designed for all individuals with higher intensity needs. This approach allows North Carolina to minimize disruptions in care, while moving toward a whole person approach. As a cornerstone of the Tailored Plans, North Carolina is designing a specialized care management program for these enrollees, spanning physical health, behavioral health, I/DD, TBI, long-term services, and non-medical factors that directly impact health, such as housing and nutrition.

With these changes, we will prioritize the health of the whole person to make North Carolinians healthier overall. It will now be easier for clinicians to refer their patients to behavioral health professionals and social support networks. Doctors will be able to work with care managers to develop plans for both physical and behavioral health needs. We want to make it easier for clinicians to coordinate with one another and with insurers so people get the right care, from the right health care professional, when they need it.

There is a lot of work to do to refine these policies and put them into practice. The walls between types of care were erected over decades and breaking them down is a big challenge. But we are taking a big step in the right direction.

Mandy Cohen, M.D. is the North Carolina Secretary of Health and Human Services. Dave Richard is the Deputy Secretary for NC Medicaid.