The average U.S. citizen lives into his/her late 70s; the life expectancy for a person with a mental disorder is 66; and if someone has a mental disorder and is a Medicare or Medicaid beneficiary, that citizen is only expected to live to (roughly) the age of 55, on par with someone in sub-Saharan Africa. To Dr. Joseph Parks, the director of Missouri’s HealthNet Division (the state’s Medicaid organization), this is “an appalling emergency” and is emblematic of a foundational problem: the U.S. health care system “depends almost entirely on the person who’s sick.” People must identify when something is wrong and determine whom to see. For people with serious mental health problems or chronic medical conditions, the results of this setup can be catastrophic.
Missouri officials became acutely aware of this dilemma in 2006 when the National Association of State Mental Health Program Directors released a report detailing the perilous experience of Medicare/Medicaid beneficiaries with mental health disorders. At first, it was unclear how to address the problem. Particularly after the onset of the Great Recession in 2008, Missouri was strapped for cash. Meanwhile, health care costs were rising. Traditional solutions, like increasing spending and incentivizing better care, would not suffice. State officials had to find a way to come together and devise a new, more efficient way to deliver care to one of the state’s highest-need populations.
The result was the launch in 2012 of Missouri’s Health Home Initiative, a program that created a place where high-need Medicaid recipients could receive coordinated care from an integrated team of medical, behavioral, and related social services specialists. The program has shifted the burden of managing care away from Missouri’s previously overwhelmed Medicaid beneficiaries and, in just three years, created $59 million in savings, reduced blood pressure and cholesterol in beneficiaries, and decreased hospital admissions and emergency room visits. A decade after recognizing a crisis, Missouri has become a bellwether for Medicaid reform across the country.
More broadly, the state’s blend of planning and experimentation is instructive for organizations attempting to scale the Human Services Value Curve. Missouri employed incremental relationship building and cultural reform but avoided unnecessarily time-consuming processes, such as building a new data management system. The implication is simple but powerful: moving up the Human Services Value Curve is ultimately an action-oriented process.
A psychiatrist by trade, Parks began exploring care coordination in the early 2000s while serving as the Medical Director of the Missouri Department of Mental Health. He started by initiating dialogues with organizations like Missouri HealthNet that were likely to figure prominently in reform. Rather than immediately issuing demands of these groups, Parks first tried to understand their problems; offered benefits (e.g., resources, fiscal freedom, and administrative assistance); and, when possible, defended them when they were under attack by others. “The best way to be a leader,” Parks later said of the approach, “is to be a partner.”
The strategy paid dividends. In the spring and summer of 2011, following the passage of the 2010 Affordable Care Act (which made federal funding available for Medicaid reform), Missouri HealthNet, the state Office of Administration, and the Missouri Department of Health and Senior Services developed a plan for health homes. Missouri then submitted two applications to the Centers for Medicaid and Medicare Services (CMS). The first would allow the state to establish health homes for Medicaid recipients with severe mental illnesses. The second would establish facilities for Medicaid beneficiaries with two or more chronic conditions. CMS approved the applications, and, in January 2012, Missouri implemented both behavioral health homes and primary care health homes statewide.
Parks and other state leaders had given substantial thought to the shape, structure, and priorities of health homes. Based in Community Mental Health Centers and primary care clinics, the groups would focus on care management, care coordination, care transitions, health promotion, individual and family support, and community services. A nurse care manager, a care coordinator, and a health home director would staff the homes, and they would be funded on a per member, per month basis.
Still, the collaborators encountered unexpected obstacles. One was encouraging the creation of a common culture. As Parks explained, every profession has a culture that dictates how people work, but staff members at health homes were in new entities and had novel responsibilities. Of particular importance were the nurse care managers, a group of nurses accustomed to caring for patients who now needed to take on a case management role. In response to this shift, Parks created forums—including phone and off-site meetings—so that nurse care managers could discuss their roles. Then, in 2013, when norms had begun to take hold, he asked the nurse care managers to create a “book of standards for what [they] should or shouldn’t do.” The team had collaboratively created a “self-sustaining professional culture” and in the process contributed to a new mindset across partner organizations: this was not just a new service or program, but an entirely new way of seeing clients. This process culminated in the Commission on Accreditation of Rehabilitation Facilities—an independent, non-profit evaluator of health and human services—requesting that Missouri help them write national standards for accreditation of health homes.
In developing plans for health homes, state leaders knew that they would need to share data so that they could evaluate their work and identify, locate, and assist beneficiaries. These state officials also knew they had an advantage: Missouri had been the first state to make available electronic health records based on Medicaid claims, meaning that (within legal boundaries) a wealth of data was available. This helped give them the confidence to use the state’s existing data infrastructure and thus avoid a common pitfall for organizations using data to propel themselves up the Human Services Value Curve: the time-consuming process of creating a brand new data management system. While building a new system is tempting because it seems it would dovetail with integration, it is invariably a time-sink. Missouri wisely prioritized expediting the start of the initiative.
Another frequent problem involving data is territoriality. If a group sees new data as part of its particular domain, it might be disinclined to share. Missouri officials mitigated this risk by creating a broad memorandum of understanding that emphasized the importance of collaboration, not ownership. This approach—and the data sharing that followed—has facilitated more substantive cross-departmental dialogue. “We found that looking at data improves relationships, as opposed to telling each other anecdotes,” Parks explained, “because everything becomes a testable hypothesis.”
Still, some staff initially felt “overwhelmed” by the task of collecting data for spreadsheets to track client outcomes; others saw the work as “burdensome.” State leaders responded by holding training sessions highlighting how data collection, sharing, and analysis could help them devise new impactful treatments. This soon bore fruit: after identifying beneficiaries who had asthma but were not using an inhaled cortical steroid, health homes staff increased use of this vital medication by 55 percent. This decreased emergency room visits (which the agency’s leaders had anticipated); it also yielded a surprising benefit: patients using this medicine experienced less anxiety and needed fewer psychiatric medicines. The reason? Before, the patients had overused another inhaler, which, as Parks explained, “made them shaky and nervous.” Now that they were taking the correct medication to prevent the start of an asthma attack, that problem had disappeared. “That is the fun you can have,” Parks said, “when you manage your programs by data.”
Three years into Missouri’s Health Home Initiative, Parks acknowledges that he has made mistakes and the program still faces challenges. Nonetheless, with more than 50 providers serving over 32,000 beneficiaries, the program has developed a substantial footprint. Having generated savings and health benefits, Missouri has also received national recognition, including the Gold Award from the American Psychiatric Association and an acknowledgment from the National Association of State Chief Administrators.
When his counterparts across the country seek advice about how to replicate Missouri’s initiative, Parks highlights several points. One is the importance of self-awareness and -actualization. Parks—who in 2013 became the director of the state’s Medicaid program—devotes half a day each week to his psychiatry practice because it helps him “see people differently.” Even more significant, according to Parks, is recognizing the need for action. “[The] most important principle I learned,” said Parks, who eschewed lengthy demonstration projects, “[is that] perfect [is] the enemy of good.”
The takeaway for agencies looking to move up the Human Services Value Curve is that it is crucial to have a plan in place (not to mention partners that back it and financing to sustain it). And once the foundation has been laid, leaders cannot look back. As Parks concluded, “It’s better to apologize for a failed, yet prompt attempt than apologize for a missed opportunity.”