Washington’s State Innovation Models (SIM) Project: Effects of Primary Care and Behavioral Health Integration on Participating Organizations

Abstract

The Triple Aim is a framework designed by the Institute for Healthcare Improvement (IHI), aimed at enhancing health system performance. The IHI Triple Aim is defined by three components: improving population health, improving quality of care, and reducing per capita health care costs. Section 3021 of the Affordable Care Act (ACA) altered section 1115A of the Social Security Act, establishing the Center for Medicare and Medicaid Innovation (CMMI). Through CMMI, Medicaid and Medicare programs can test models to improve care, lower cost, and support patient‐centered practice. The State Innovation Models (SIM) initiative is one of these major reform models and is designed to test new payment approaches that address the Triple Aim.In Washington State, SIM Payment Model 1 (PM1) assists the transition from the traditional Medicaid payment system, with separate contracts for physical and behavioral health services, to a unified managed care model wherein each Medicaid managed care organization has single contract for delivering physical and behavioral health services. The primary goal is to incorporate behavioral health benefits into the capitated Medicaid managed care program so that beneficiaries have access to the full complement of physical and behavioral health services through a single integrated managed care plan. Our purpose is to evaluate stakeholders’ perspectives regarding the impact of the SIM PM1 initiative on participating payers, providers, and support agencies.The lead qualitative investigator contacted a purposive sample of clinical and administrative executives via email between June 2017 and October 2019. A total of 23 informants (n = 23) representing 11 organizations participated in a combination of face‐to‐face and telephonic interviews. Semi‐structured interviews were conducted using a single questionnaire aligned with an organization theory‐based conceptual framework, and each lasted 37 to 70 minutes.The research team identified health service payers (MCOs), behavioral health and primary care providers, and supporting agencies (eg, public health, crisis services, associations) participating in the development and/or implementation of PM1 physical‐behavioral health care integration initiative.PM1 implementation efforts required extensive consideration of organizational needs as well as agency‐based integration techniques. Integration depended on external and internal contributing factors, which informed and guided changes to the organization theory‐based conceptual framework. Efforts were influenced by a combination of external and internal factors, such as regional leadership and partnerships as well as each entity’s unique capacity to engage in organizational learning. While stakeholders expressed wide‐ranging opinions about the initiative and its effects, informants’ perspectives aligned largely by organization type. Thematically, findings included (a) organizational change management; (b) key priorities and approaches; (c) common facilitators and barriers to integration; (d) lessons learned; and (e) sustainability.Contextual factors influence organizations’ unique approaches to adoption and implementation of physical and behavioral health care integration policy. Value‐based policy implementation is a learning process. As such, organizations must hone their approaches to services delivered over time.When setting priorities for value‐based contracting, policy makers and health system leaders should consider the contextual and organizational factors that influence implementation, and should explore payment and purchasing structures that allow for flexibility and learning, particularly during early implementation.The study was funded by the Centers for Medicare and Medicaid Services.