In February 2016, Gov. Rick Snyder shocked the health care community when, in Section 298 of his Michigan Department of Health and Human Services’ (MDHHS) budget, he proposed that the state unify the Medicaid physical and behavioral health systems.
To the average observer it may not seem like much, but to the state’s health organizations, the Michiganders who have behavioral health issues and the families and organizations that advocate for them, it was like dropping a bomb. “Although there had been discussion about the integration of physical and behavioral health under Medicaid, I don’t think anybody saw it coming this quickly,” says Peter Pratt, president of Public Sector Consultants (PSC). “This was a surprise to virtually everybody.”
Some background here may be helpful. Under the current system, the Medicaid Health Plans are responsible for managing the delivery of physical health care services — that is, services delivered through the traditional medical care system where doctors primarily treat people for illnesses, injuries and so forth. These health plans also cover limited mental health services. Patients are allowed up to 20 visits per year for the treatment of mostly mild to moderate mental health issues.
Regional public authorities, on the other hand, which include Community Mental Health Services Programs (CMHSPs) and Pre-paid Inpatient Health Plans (PIHPs), are responsible for managing the delivery of behavioral health care services and treating people with more severe mental illness, intellectual and developmental disabilities and substance use disorders.
There is a growing recognition among health care consumers and professionals, however, of the connection between physical and behavioral health. Research shows that people who have severe mental illness also usually have multiple physical health conditions that, ideally, should be managed together. The thinking, therefore, is that if the state can find a way to better integrate care, then overall health outcomes will improve.
Bright Ideas spoke with Peter Pratt and Jane Powers about the process they used to make sure diverse stakeholder voices were heard while trying to navigate the opportunities and challenges presented by Section 298.
What problem was the governor trying to solve? Was he trying to move the health care system closer to treating the whole person in one place?
Peter: Yes, I think so. The challenge is that we’re talking about integration of care at two levels — the individual level and the system level. On the individual level, if any of us had physical and behavioral maladies, we would certainly want our primary care physician, who tends to be more focused on the body, to be aware of our mental health issues and our psychiatrist or therapist to be aware of our physical health issues. On the macro level, however, physical and behavioral health issues fall into two big buckets that are administered by completely different organizations at the state, regional and county levels. When administration is separate and the rules are separate, the chances of getting down to integration at the person level are slim. I think the governor’s hope was that we could join the two systems in a way that would facilitate better care coordination for individuals with significant behavioral and physical health issues.
Why was there such concern in the health care community when Section 298 was presented as part of the budget?
Peter: I think it was because, while many other states have integrated their systems in some way, people with behavioral health issues and their families are concerned that the Medicaid Health Plans may not be able to handle this because they haven’t lived in this world. Even though the budget language stipulates that the health plans contract with local community mental health agencies, some people fear that behavioral health will be slighted. That’s what led Lt. Gov. Brian Calley to convene a group of stakeholders to explore the different ways Section 298 might be modified and implemented.
The Behavioral Health Section 298 Workgroup has 122 people in it. That’s very large, isn’t it?
Jane: Yes, but it was necessary. The lieutenant governor said he wanted a workgroup that would bring together diverse stakeholders. As the MDHHS began putting together the invitation list, they found they needed to keep adding to it to make sure there was representation from the many organizations and individuals that might be affected by the boilerplate.
Peter: There’s a very robust advocacy group in behavioral health, maybe more so than in any other area of health care. So, we needed to have a lot of people at the table. The lieutenant governor and the department could have put 10 experts in a room to bang out a solution, but they knew they would get more buy-in and a better solution if they worked with a broader group. Given what’s at stake here — we’re talking about people’s lives — we think that was a wise choice.
Why do you believe MDHHS chose PSC to facilitate the workgroup?
Peter: We were approached by the department to facilitate this process, in part, because of other large-scale facilitation work we had done for them in the past. Also, we have several clients on different sides of this issue, which means we can look at it from multiple perspectives. Finally, our clients were comfortable with us taking on this role because they knew we didn’t have a dog in the fight; we were in favor of integration, but we didn’t have a stake in what was decided. The only thing we wanted to be sure of was that the process allowed stakeholders to truly participate in the conversation. Obviously, that was important to the department as well.
Jane: I think another reason MDHHS came to PSC is that we’re familiar with health policy broadly and we have a good understanding of both the medical care and behavioral health systems. Both our content knowledge and facilitation experience contribute to our ability to hear what’s being said, summarize in a way that’s accurate and frame the issues appropriately. We give legitimacy to the process.
When a client comes to you with such a complex issue, a large number of invested parties and so much at stake, where do you start?
Jane: Before there is ever any kind of meeting, before an agenda is developed and before questions are crafted for discussion, we’re in very close communication with our client to get a good understanding of what they want to accomplish. Where do they want to head? What are their concerns going in? That helps us figure out the best approach for achieving their end goal. Then, we meticulously lay out a plan from beginning to end to accomplish the agreed-upon objectives.
Peter: We also spend time internally talking about what can be accomplished. For example, on this project, the main thing we arrived at early on is that you can’t design an improved system with 122 people in the room, especially in such a short timeframe. The original schedule only allowed for four two-hour meetings, which we expanded to five. Still, that meant that anything we did had to be completed in just 10 hours. Clearly, that’s not enough time to fully integrate two very complex systems of care. Ultimately, we determined that the workgroup needed to build a foundation for the more detailed work that the department and other stakeholders would have to do later on. We also realized pretty quickly that we had to start at a fundamental level — agreeing to a set of core values.
Can you give us an example of a core value and how you got the group to agree to them?
Peter: One example is that the group believed that an individual’s needs for services and supports, not the budget, should drive person-centered care plans. To identify this and other core values, the department put together a list of values they had used in previous work and that served as the baseline for the workgroup discussion. Then, we asked the group as a whole to refine the list. PSC took what everyone said, organized the suggestions into categories and asked workgroup members to vote on the core values document at the next meeting.
Jane: To vote, we used a stoplight approach where green cards mean “I support it;” yellow cards mean “I support it with some reservations, but I can live with it” and red cards mean “I don’t support it.” We’re not, of course, looking for complete consensus — you’re never going to get unanimity with a group that large — but we wanted to see at least two-thirds of the group supporting the values with a green or yellow card. People who raise a yellow or red card are given a chance to share their concerns and offer amendments. This is one of the ways we make sure everybody has a chance to express their opinions.
Once the group agreed to the core values, what happened next?
Peter: We spent the next two meetings helping the group brainstorm what was and was not working well with the system, and what could be done to make it work better. Then, at the fourth meeting, we broke them into small groups to talk about what design elements are needed in an integrated system. We focused on three areas: delivery, administration and oversight and payment and structure. Each small group voted on the three to five design elements they wanted to share with the full group, and, at the final meeting, everyone voted on the ones they believed would best reflect the core values. All of this work has helped to lay a foundation that can be used in coming months as the department figures out how to move forward with building an improved and integrated system.
I know PSC developed a detailed process describing what would happen at each meeting in order to achieve the department’s objectives, but do these kinds of groups ever go off course or decide they want to change the process?
Peter: That actually happened early on. Some workgroup members suggested that the group spend time proposing revisions to the Section 298 boilerplate [language that stipulates how money in the budget must be spent], which was not on our original list of deliverables. After the group decided it preferred the House version, we asked for revisions to the language, but it took a lot more time than expected. People were amending the original language, then amending each other’s amendments and so forth. So, while we were in the meeting, we decided that we needed to use a different approach. We ended the conversation, asked people to submit their changes via e-mail after the meeting, sorted through and organized all the recommended changes, sent the suggestions out in a document before the next meeting and asked people to come prepared to vote yes or no on each of the suggested revisions. The changes approved by the workgroup were then passed on to the appropriations subcommittee chairs.
What did you learn, if anything, from that curveball?
Peter: Even though it wasn’t part of our plan, I don’t think we would have been able to move forward without having had that particular discussion. In fact, several people we’ve talked with over the course of the process have said that, perhaps, the most important outcome of this process is that people with diverse positions and interests are learning how to work and talk together in a way they haven’t before.
Jane: You always have to be prepared to adapt and revise your process at any point, sometimes even during the meeting. You draw on your past experience, your knowledge of the people in the room and your content knowledge in order to do that. For example, our experience doing this kind of work in health care allowed us to recognize that while the boilerplate conversation wasn’t part of our original plan, it needed to happen, even if it was taking up valuable time. We didn’t just put it in a parking lot, which is a common facilitation tool. We figured out a way to listen and respond to the group’s desire to talk.
Peter: I also think the way we write meeting summaries helped us here. We don’t prepare minutes — a chronological description of who said what in what order. Instead, we write meeting summaries that distill the conversation in a way that organizes information by theme, while keeping enough of the original content that people can see their contributions reflected in the text. When we used that approach with the boilerplate revisions, it helped people sign-off on them and move on to the next step.
So, now that the workgroup has had its last meeting, how do you define success from PSC’s perspective?
Peter: To me, success is fulfilling the deliverables we identified at the beginning of the process. We gave the department core values and a pretty comprehensive list of design elements for an integrated system that have consensus from multiple and diverse stakeholders.
Jane: Did we produce what we intended to, while allowing everyone to be heard? While the latter is hard to measure, we often had people come up to us after our meetings to say they really appreciated the chance to be heard and that PSC’s facilitators did a really nice job of making everyone feel welcome in the discussion. Success is having the people involved feel like the process was worthwhile.
Why does PSC do facilitation work? How does it advance public policy?
Peter: I feel like PSC has been very fortunate to be put in the middle of some really big issues and we’re proud that people look to us to help forge consensus. That, to me, is exciting because we’re not defending the status quo — we’re trying to find the best way forward. I feel like our approach gets people thinking about the best ways to make policies or systems better, rather than finding the least common denominator we can agree on. If you can get more than 100 key stakeholders to reach agreement on an important and complex issue, then the executive branch and the legislative branch are inclined to listen.
Jane: I agree with Peter’s emphasis on better. This kind of work allows us to be involved in doing something that’s better for the people of Michigan. It’s our way of contributing to improvements in overall health.