A Day in the Life of a Managed Medicaid Behavioral Health Behavioral Health Medical Director

By Dr. Sosunmolu Shoyinka
Begin with the end in mind.... The 2nd of the habits propounded by Stephen R. Covey.

I start my day by mentally reviewing my overarching goals. In formulating the objectives that underlie my activities in this role, I have drawn heavily from Ekong’s paper on this role and from discussions with seasoned colleagues.

My goals are to
• Resource the health plan clinical teams.
• Resource our provider network.
• Resource the system of care, as best I can.

I make certain to get an early start, particularly since my to-do list today consists of 3-4 hours of driving to and from meetings. Included are a series of provider visits, a public-policy workgroup meeting with key stakeholders, clinical team meetings to discuss complex cases in two of the four health plan markets that I support and, most crucial of all, a high level state meeting to discuss the system of care in one of the states I support. As I have intimated in a previous post, one of the things I enjoy the most about my current role are the myriad opportunities to learn about how the health system really works. There are daily lessons to be gleaned on health policy, health system oversight, health system financing, advocacy, provider relations, contracting, high-level strategy and how all this affects the delivery of care. It is an on-the-job equivalent of an MBA in some respects, in my opinion.

My first meeting is at 8am, with a provider whose office is an hour away. I see this as not just an opportunity to address the content of our meeting, but the context as well, by which I mean the MCO-provider relationship. Today’s meeting is ostensibly about addressing average lengths of stay for individuals with complex needs in this particular facility. In my opinion, the bigger objective is to develop a more collaborative working relationship. As I have previously written, the reality of working in a Managed Care environment is that the relationship between direct service providers and managed care staff often begins with little trust on either side. Clinical experience, backed by tons of research, has taught me that the most important predictor of outcomes in working with others is the strength of the alliance. Therefore, retaining an adversarial tone to the working relationship leads to poor outcomes. So I have decided that one of my core tasks is to build strong working relationships with provider colleagues. I anticipate that this will lead to better outcomes for our members, while improving quality and reducing overall cost.

I have found my psychiatry training and experience invaluable in working in this environment. Skills that are particularly useful are active listening, the ability to re-frame issues in a way that focuses on the problem and not the personalities, the ability to read non-verbal cues and to respond appropriately to moments of tension in a dialogue and in being able to work with others to develop a working alliance. Not that I would ever act like a psychiatrist in a non-clinical context, right?

We discuss the progress that has been made over the past year, and proposals around further reducing lengthy hospital stays that are not a result of medically necessary treatment. Many of the ideas we discuss come from our provider colleagues, suggesting that we are becoming collaborators and allies, rather than adversaries. However, it is early days yet and we have a lot of work to do. We conclude with a proposal for a contractual agreement that, if structured well, would give the provider more autonomy in providing needed care while reducing the administrative burden of frequent concurrent reviews on both sides. My colleagues from the health plan and I briefly confer after the meeting and agree that the tone of the relationship seems to be improving. I leave this meeting with a sense of hope. Such a small step, but one that could have profound ramifications for how care is delivered to this population.

My next task for the day is to conduct clinical rounds, during which our team discusses members with complex needs. These members are often high utilizers of inpatient units and emergency room - in short, more expensive services. They typically have some combination of severe mental illness/emotional disturbance, substance use disorder, history of involvement with corrections or criminal justice, medical problems, and significant social stressors. Our team comprises case managers, utilization managers, care coordinators and intensive case managers. They are typically former direct-service providers/clinicians who have made the transition to “the dark side” for many of the same reasons as I have - frustration with the systems of care, and a desire to make a difference. The rounds serve multiple purposes: Internally, it is a forum for identifying high utilizers (or, to use the term coined by Atul Gawande, “hot spotters”) and for developing proactive, coordinated care plans which aim to improve their outcomes while simultaneously driving down costs. The rounds also serve as a learning collaborative and an opportunity for team members to discuss challenging situations, a strategy which has been shown to reduce burnout among clinicians. For me it is an opportunity to learn the individual markets - resources, providers and challenges in accessing care. I also see it as an opportunity to shape our team’s thinking and approach to working with members, by sharing practice guidelines and the current literature on various issues. I find that my prior experience working with residents is very helpful in this regard. Externally, it is an opportunity to engage our provider network and to shape provider behavior by educating them about medical necessity criteria and discussing expectations of care as a health plan. I also provide support to our network providers, many of whom are not psychiatrists. In discussing cases, I apply what I have learned from my training in Psycho-somatic Medicine and from consulting to primary care providers in my "past life". I usually offer suggestions based on my review of the case, the literature and from my own practice. I often detect an undercurrent of surprise from providers as my goal is not simply to approve or deny care but to equip the provider with knowledge and information that they can apply to working with their entire caseload. It is applying the aphorism "teach a man to fish".... to be continued.