Behavioral Health Reform: Meeting Coloradans’ Needs

Behavioral health is a profound and persistent challenge in Colorado.

In 2019, 15.3% of Coloradans reported poor mental health and 95,000 reported that they went without needed substance use disorder treatment, according to the Colorado Health Access Survey. Suicide was the leading cause of death among Colorado youth.

To respond to this challenge, Gov. Jared Polis convened the Behavioral Health Task Force in April 2019 with the goal of ensuring that everyone with behavioral health needs receives timely, equitable, high-quality services. What no one knew then is that one year later, Colorado, and the world, would be facing a pandemic that has changed many aspects of how we live and further exacerbated mental health needs.

Last month, the task force released its Blueprint for Reform, an ambitious three-phase plan that has the potential to significantly improve behavioral health in Colorado. (See sidebar.)

At the Colorado Health Institute (CHI), we have been tracking and contributing to the development of the Blueprint. Earlier this year, CHI quantified the financial landscape of Colorado’s behavioral health programs and agencies on behalf of the Task Force, reinforcing how truly complex the system is. Timely treatment for behavioral health is critical, yet consumers have continually found Colorado’s system to be hard to navigate, leaving them without supports and resources when they are needed most. CHI’s analysis included a financial map displaying the fragmentation of the current system: Over 75 programs and 10 different state agencies support behavioral health services for kids and adults in the state.

The Blueprint is a promising step toward addressing this and other pressing challenges facing the behavioral health system, such as access and affordability. Now, we at CHI are also thinking about the questions it raises, including the drivers necessary to make significant changes, such as funding and legislation.

Where’s the money?

Given the 2020 economic downturn, budgets across the state have tightened. Phase One of the Blueprint will create a Behavioral Health Administration (BHA) which will be responsible for delivery of services and leading transformation of the system. This will streamline agencies and programs, reduce duplication of efforts, set clear priorities for improvement, and ultimately, consolidate funds. Other funding options, such as nonprofit hospitals’ community benefit spending, will also be explored in Phase One. Historically, Colorado’s hospital community benefit spending has gone to direct uncompensated patient care. However, the passage of Colorado House Bill 1320 in 2019, which required greater transparency and accountability from hospitals on community benefit programs, may pave the way for collaboration with the Task Force and redirect spending to support implementation of Task Force recommendations.

Is a care coordination model the correct approach?

In Phase Two, the BHA will implement a care coordination model intended to create a single point of entry for the programs and services accessed by consumers. Many have expressed skepticism regarding use of the model. But, if successful, the establishment of regional care coordination structures will help patients and families navigate the behavioral health system.

The model will not only integrate mental health and substance use disorder services, but also programs that address social determinants of health such as housing, transportation, and employment. It will also alleviate the concerns of countless members of the public who have expressed feeling lost in the shuffle between programs and services or had to re-experience traumatic events by retelling personal stories to different people, representing different programs, over and over again. 

About the Blueprint for Reform

The Blueprint for Reform outlines critical and essential steps to transform Colorado’s behavioral health system in three phases. Some key activities in each phase are:

Phase One:

  • Create a Behavioral Health Administration (BHA), a new state agency or entity within an existing state agency that will lead reform and be accountable for delivery and transformation of behavioral health services in Colorado
  • Expand telebehavioral health services
  • Identify legislative opportunities and new funding sources

Phase Two:

  • Develop an implementation plan for prioritized Task Force recommendations, including the establishment of a care coordination model
  • Address 19 prioritized recommendations across six key pillars: access, affordability, workforce and support, accountability, local and consumer guidance, and whole person care

Phase Three:

  • Assess and plan again to ensure the ever-changing needs of Coloradans are consistently met

How will the BHA balance the shifting policy landscape around telemedicine?

Telebehavioral health services have become a critical source of care for many since the start of the COVID-19 pandemic. State and federal policymakers have increased access to telemedicine during the ongoing public health emergency, but the BHA will need to plan for the potential repeal of waivers that allowed that increase. Payer reimbursement policies, adaptations for the use of telephone and live chat, and the use of HIPAA-compliant platforms are just some of the issues the BHA will need to address. An executive order issued October 3 calls for an increase in the availability of telehealth services by encouraging – and possibly funding – organizations to promote both in-person and telehealth activities in the long term, which may help boost these efforts.     

How will the BHA increase access across all insurance types?

Health First Colorado, (Colorado’s Medicaid plan), covers over 1.3 million people – over 22% of the state’s population. But the Department of Health Care Policy and Financing (HCPF), the state’s Medicaid agency, and the Division of Insurance (DOI), will not be a part of the BHA. Instead, HCPF and the DOI have committed to lead the conversation and align with BHA recommendations. The extent to which Medicaid and private insurance efforts will be integrated into the BHA will also be explored in Phase One.

However, alignment between payers is essential to successfully implementing many of the Blueprint’s recommendations. For example, standardizing guidelines across public and private payers so that more providers are in-network has been identified as an opportunity for improvement – more in-network providers will provide more Coloradans with options when seeking care.

But how will the BHA incentivize providers to join the networks to begin with? Rates of payment and reimbursement from payers are a longstanding issue for many behavioral health providers. Payment for care coordination services is also a concern. The BHA will have its work cut out for it in attempting to implement consistent, fair, reimbursement rates for behavioral health services across payers. Both HCPF and the DOI stated in a virtual town hall meeting on October 7 that they will rely on the BHA to develop the care coordination model and determine what the appropriate rates should be and reiterated their commitment to align with BHA priorities and recommendations, but questions remain about the extent to which this will happen.

Looking Forward

Improving behavioral health care in Colorado will not be an easy feat. The questions above are just some of the considerations that have come up, and it is clear that an overhaul of the current behavioral health system in place will take time – and money. In addition to many deep-rooted complexities in the health care system, issues like stigma associated with mental health or substance use are difficult to change no matter what policies are in place.

How will the Blueprint meet the needs of people today and build upon the work many providers across the state have tirelessly advocated for? Many of the Blueprint’s longer-term recommendations will require legislative change and significant transformation to the system. But the creation of a new behavioral health administration and expanding telebehavioral health services are first steps toward ensuring that all Coloradans have improved, immediate access to the care they need, when they need it.

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