Best practices in rural Medicaid managed behavioral health

OVERVIEW: Most states are currently enrolling some or all of their Medicaid population in managed care, and many are choosing to separate the financing and management of mental health from physical health benefits. These arrangements are often referred to as mental health carve-outs. In 1997, staff at the Maine Rural Health Research Center completed a study of six rural states that had implemented managed mental health in their Medicaid programs. One major finding of that study was that states have not taken advantage of the experience of other states as they implement these programs (Lambert et al, 1998). With this series of papers, we hope to encourage states that are designing or modifying their Medicaid mental health programs to consider the "best practices" of other states. These papers are designed to develop practical and useful guidance for states and managed behavioral health firms on approaches and strategies for addressing the special needs and circumstances associated with implementing a mental health carve-out in rural areas. While managed behavioral health raises many of the same concerns currently being raised about managed medical care, such as provider choice, use of financial incentives to limit appropriate care, and interference with the physician-patient relationship, this series of papers is narrowly focused on those issues with a unique rural element. In our previous study, we identified several such issues. After consulting with national experts in the field of managed behavioral health, we selected four topics for inclusion in this series. Since insufficient access to a wide variety of services has been a constant theme in rural studies, and access to mental health providers has been especially hard to achieve, we begin the series with "Measuring and Monitoring Access". Those who read all four papers will find that access and under supply of providers and services are mentioned throughout the series. Similarly, the significant role of primary care practitioners in providing mental health services in the absence of mental health specialty providers is a recurring theme in this series. These recurring themes have resulted in some repetition in the series. Since some readers may not read the entire series, we feel that such redundancy is unavoidable. Each paper can be read as a separate piece. In each paper the authors have presented some background material by way of indicating what problems exist and why this topic was chosen for the series. We then present "best practices", specific programs, policies or practices that are currently being used in one or more states to address those problems. In many cases, the interviews and research conducted by the authors turned up practices that are being considered or recommended in one or more states. We have labeled these "recommended practices" because they have not yet been tried and proven, but appear promising. Because managed behavioral health is relatively new to Medicaid programs, neither our best practices nor our recommended practices have been rigorously evaluated. Several of the states cited in these papers for their best practices are having their practices formally evaluated as required for 1115 demonstration waivers. As results of those evaluations become available, our recommendations may be modified. On the other hand, early results of evaluations have not been directed toward rural issues. It is our hope that Program Directors, policy makers, and practitioners can make use of the information in these papers, in the absence of rural-focused evaluation results. Such users may wish to contact the respective authors for the most current information on a specific practice. We expect that these programs will continue to be works in progress, with constant innovation and modification to meet the changing needs of Medicaid enrollees, and to respond to other policy initiatives such as welfare reforms, children's health insurance plans (CHIPs), and other legislative, organizational, and financing changes.