Can Better Program Integrity Lead to Better Behavioral Health?

Alyssa Lord
Where we see the strong success is really around talking about the value and definition of program integrity and framing it as quality improvement rather than policing.

Jennifer Colamonico
You're listening to Vital Viewpoints on Healthcare. Let's get started. Today I'm joined by Alyssa Lord, a principal at HMA and a nationally recognized behavioral health leader with deep expertise in Medicaid, population health, value based care, and integrated care delivery. Before joining Health Management Associates, Alyssa served as Deputy secretary of Maryland's Behavioral Health Administration, where she helped lead policy and strategy for a $3.5 billion behavioral health system.

Her work is focused on improving access, advancing equity, strengthening community based services, enhancing quality, and ensuring program integrity across complex health care systems. We're excited to talk with Alyssa today about the future of behavioral health, how we support providers, and how we build systems that deliver better outcomes for the people and the communities they serve. Alyssa, thank you for being with us today.

Alyssa Lord
Glad to be here.

Jennifer Colamonico
Two very, timely topics behavioral health and Medicaid. So I'm really excited to dive into this and learn more about your experience there. So, thinking about that time that you served as deputy secretary in Maryland. What challenged your assumptions most about how behavioral health systems actually function? What did you kind of not expect when you took the job?

And, you know, what was really surprising to you in your work there?

Alyssa Lord
And I appreciate the questions. And for me, you know, what I found is there remains a significant disconnect between how we continue to view behavioral health needs and how we think about whole person care. The head is not disconnected from the rest of the body. However, we have continued to create silos and still have much work to do about integrated systems of care and care delivery.

Jennifer Colamonico
I'm not sure a lot of people understand the kind of intersection between behavioral health and Medicaid. When we think about maybe those more familiar with the Medicaid program generally, what do they kind of misunderstood about the complexity of serving these patients that are inside Medicaid, but have these significant, behavioral, needs and also clinical and social needs.

Alyssa Lord
Across behavioral health and the broader somatic health care landscape. We have created a very complex health care ecosystem that is difficult to navigate. Often it is not intuitive, it is taxing. And there are barriers that delay receiving good, high quality care for individuals or families that have complex needs. There are challenges with network adequacy, access, stigma, and parity limitations.

I do want to assert that, you know, in spite of what seem to be these these insurmountable or intractable issues, there are tremendous providers and community health workers, peers, family members, etc. who work tirelessly to ensure people, regardless of their insurance status, are getting services.

Jennifer Colamonico
They're working hard for that. And you wonder, they shouldn't have to work so hard, right? Because we have a very uncoordinated system. And, you know, as you mentioned, the head is not disconnected from the body. So in your time in Maryland, you invested in creating a more coordinated behavioral health system. What does that look like? What does that mean to be more coordinated?

And how can other states learn from that?

Alyssa Lord
Well, first and foremost, I was incredibly grateful that we had the support of the governor, the General Assembly, the provider community, and the Marylanders that were recipients of care to take a critical look at Maryland's continuum and identify opportunities and gaps. You know, what emerged was that the stakeholder voice was paramount. And that there were they were key in many instances in identifying solutions.

Another lesson was having the programmatic and fiscal support to make strategic but sometimes incredibly difficult decisions. One other element, which this is certainly not all encompassing, but was devising a path to quality and outcomes, you know, how are we measuring service delivery? What are those performance measures? How are we calculating the return on the investment? How are we ensuring people are getting timely and quality care?

And I think this is a conversation that not only Maryland wrestle with, but that we're seeing this as a national paradigm in discussion.

Jennifer Colamonico
So what's an example of a strategic but difficult decision that you had to make there?

Alyssa Lord
This sort of leans into the fragmentation and the breakdown in communication in an uncoordinated system. But what we had found was our kiddos were really struggling, and we had built the foundation through our 1959 Home and Community based services program. But we set the bar for admittance into those services so high that it wound up creating a disincentive for youth and their families to be able to access that care.

So we worked with, stakeholders. We worked with parents and families. It was very much a community based approach that we took to identify what were those barriers and what were some of the solutions. And within a year, we had revised and resubmitted and had received approval for a revised 1959 that increased access and lowered the barriers for families to begin to be able to access those services.

And we also worked with our families and our communities to figure out what is the appropriate messaging, so that they knew that those services were now available, because previously the impression was don't even bother.

Jennifer Colamonico
Well, we have a situation where we're expanding coverage, and trying to get more people access to services. But we have a limited number of providers. What kind of resources do you look to try to expand that capacity? And I want to talk about program integrity in a moment. But I think it's important, to understand the ebb and flow of, you know, trying to bring more services to families, to meet needs that are unmet by the current system and expand capacity and the challenges therein.

Alyssa Lord
We had to meet with our provider community to understand their limitations. Some of them were programmatic. Some of them were policy, some of them were fiscal, some of them were regular story and statutory. It wasn't parallel tracked, but there were similar timing, in the state of Maryland, worked with the provider community to completely rewrite the code of Maryland regulations with governs behavioral health services so that we had more transparent, cohesive and coherent regulations that would hopefully attract and retain providers to Maryland.

And it was also, where Maryland is currently undergoing a, a rate study in which providers have a seat at the table to understand where do we need to either balance, rebalance or identify additional resources, which in a in a very resource constrained time is difficult. But because we had such tremendous support at the state level through the, you know, the governor and others, I am optimistic that, you know, Maryland will be able to develop a strong pathway for attracting and retaining new providers.

Now, Janet, it doesn't address the broader concern around the behavioral health workforce shortages, but there is also currently work underway in Maryland to take a look at what are some of the strategies that can be deployed to better support attracting and retaining behavioral health workforce.

Jennifer Colamonico
The work that you did, really, in terms of understanding your providers needs and how to engage them, how to bring more in, you know, we we are in an environment right now where there's a lot of conversation around program integrity, which is often framed as, you know, in the negative catching bad actors, that implies, you know, intentional fraud or abusive patterns, fraud, waste and abuse.

Right? With those three being very different terms. But, you know, without acknowledging the good actors, right? If there are bad actors, then there have to be good actors. And when we talk about quality care, you know, to your point, we need to define what that is. So talk a little bit about what you did around program integrity and how it's been defined.

More broadly as, as, I don't know, not so punitive and negative, but really has an opportunity to improve quality.

Alyssa Lord
You know, that's a good question. And I'm actually going to start with the second part of your question first. And you know, unfortunately we start from a place of only focusing on being on the bad actors. As you've mentioned, Neal, from my perspective, it's a constellation of different facets, including the various systems and policies and safeguards regard rails that support patient access, patient care, patient safety and quality.

You know, this definition also needs to include the clinical and fiscal lens that are currently tied to program integrity. I understand the need to focus on fraud, waste, and abuse as it can completely upend the trust in systems of care and deplete necessary fiscal resources from states and counties. But there's also an opportunity to program integrity, to uplift the great work that providers are doing through such things as performance based measurement and assessing outcomes, and exploring alternative payment models such as value based care, to incentivize high quality.

And that also then dovetails with the last question that you had asked around, you know, what are ways that we can identify or expand provider networks, or bring providers into the fold to provide that good, high quality care is is thinking through strategic and innovative ways, besides just rate reform, are there other alternative payment models that would benefit not only the individuals that they're serving, but maintaining longevity in service provision?

And from some of the work that we did in Maryland was in 2024, we had worked with our partners at CMS and received approval for a moratorium on three services in which we had seen exponential growth and utilization with very, very or little actually, to no outcomes of the individuals that were receiving services. So we paused new provider enrollment into the Medicaid so that we could better understand and assess the quality of care that people were receiving, the churn in care that people were receiving.

And we, for the most part, received tremendous support from the provider community because they had been expressing similar concerns. And that, you know, we want to make sure that people are getting good, high quality care that we're monitoring for transitions of care if they're moving from provider to provider, and it was difficult for us to do, given just the vast number of new providers that had entered the market during that period of time.

And so it, and as I mentioned before, it also aligned with the work that we were doing around rewriting the regulations.

Jennifer Colamonico
So what kind of blowback did you experience when you paused enrollment?

Alyssa Lord
For new providers who are looking to enroll in Medicaid? It was a challenge for them because many of them had hired staff. Many of them had secured space. And so we worked with those providers to understand that just because you couldn't enroll in Medicaid does not mean that you could not provide care through other mechanisms. So we encourage them to partner with commercial payers, or not dissimilar to some of the the work that we've seen in FCS, for example, where you can have a sliding scale so that you don't have to disadvantage a community.

While the state is looking to ensure that we are building a strong quality continuum of care and mitigating those bad actors.

Jennifer Colamonico
Well, I think the point that you're making is, you know, most providers want to do the right thing. They want to provide the quality outcomes. That's why they go into business. Right? So, into the practice, so, you know, how talk about your partnership with providers. I mean, I'm sure that it was difficult as you went through this, this process, even if they want to do the right thing, that may seem like unnecessary burden or that may seem, you know, like asking them to jump through hoops.

So how did you kind of balance that and get them aligned with, with this sort of new approach to program integrity?

Alyssa Lord
Well, I think to your point, it was really around talking about the value and definition of program integrity and framing it as quality improvement rather than policing. You know, for many of our providers, where we see the strong success is when they embed program integrity and quality into their day to day operations, from the construct of their policies and procedures, to the onboarding and training of team members, to investments in infrastructure and architecture, to even their own internal compliance programs that they build.

You know, ultimately, the end goal, which I do think is the case for most providers, is that they want to render good care and they see program integrity as a core value, not something that is separate or apart or a regulatory or statutory requirement. It is part of their mission and vision for care. And when the state is able to underscore that with the provider community, it takes away some of the abrasion of this solely being intentional to have a punitive effect.

Jennifer Colamonico
How important were the regulatory changes? When you think about applying the lesson to other states, you know, you were doing all these things at the same time, tremendous undertaking to do it all at the same time. But do states have to consider regulatory changes in order to really do this right? Or, you know, what is the kind of, element of the regulatory changes that really was most critical to success?

Alyssa Lord
So from Maryland's perspective, our regulations hadn't been updated in nearly a decade. So there was an element of not only what was happening at the national level. But also the continuum, the behavioral health continuum of care that had evolved over that decade had changed. And so we needed to review the regulations to be timely, accurate, reflective of the model of care that we wanted to see for Marylanders.

And so I think for states, they don't necessarily have to do a full sweep of their regulations. But I do think it is important for states to understand where might they need to pivot or adjust regulations. It doesn't have to be year over year. That is a Herculean lift. But as part of the stakeholder engagement piece and having their finger on the pulse with the provider community is having a regular feedback loop that allows for thoughtful, intentional, and subjective review of the regulations to make sure that they are aligning not only with program integrity, but how we are thinking about those elements that I talked about before, which is, you know, performance based measurement and quality outcomes and incentivizing for good care.

Jennifer Colamonico
How do you balance what is the biggest lesson that you learned in terms of, you know, reducing the abrasion administrative burden on providers and yet achieving, you know, increased quality outcomes, and sort of those models of care that you talked about, you know, what does what does it mean to reduce administrative burden? I feel like that's often a very broad brush that's painted.

What is really the most burdensome, you know, regulatory or administrative request that that is maybe unnecessary here. Any little gems that you learned along the way?

Alyssa Lord
Yeah. So I was really fortunate that during my tenure, I was able to visit pretty broad swath of providers. And, and there are reoccurring themes that I heard time and time again, which is lots of duplicative paperwork. There are inconsistent requirements, which is why we went back and work to modify the regulations. There. Unclear rules. You know, Maryland is, a behavioral carve out.

And so we had partnered with an administrative service organization, and, and we had relied on, our conversations with the providers for, even for them to bring to us where they found inconsistencies in our ASL manual, which, you know, isn't meant to throw anybody under the bus, but really just trying to think about how are we promulgating rules or, instruction and and yet they're not clear for the provider community to be able to execute.

And then I will also say, you know, repeated documentation requests prior authorization delays, and overly sometimes I will say sometimes overly cumbersome audit processes that can consume time without clearly improving care quality or accountability. I will add a little bit of an asterisks to this, where you know what makes this a little bit more difficult is the ever changing landscape, at the federal level at this time.

And so while states are working to ensure stability and care, when we think about these additional administrative burdens that are placed on providers, it really does require state and federal cooperation and coordination to think about, you know, what does that look like as a path forward?

Jennifer Colamonico
Yeah, just such a swirl of changes just in the last month. Some of which do seem to add administrative burden, ironically so as they're seeking to reduce, fraud. But, more to, to be understood on that. But as you think about reducing duplication, how much does technology, play a role in all of this.

Alyssa Lord
Technology continues to evolve every day. And and it should help prioritize meaningful signals, not generate more tasks. This may be overly simplistic, but either creation or better dashboards. Sharing data sources, thinking through what processes can be automate and whether it's validation or prior authorization. And I know we're moving in that direction. And then the other piece I will say is really thinking through how do we optimize predictive analytics so that we can help identify what those outliers are and emerging risks.

And hopefully that will then mitigate one off requests, you know, manual submissions to fix these, these various different technical issues, and repeated collection of information when it may already exist for the state or the plan.

Jennifer Colamonico
You talked about being a carve out state, and I, I know I've certainly heard even among like FAQs, for example, qualified health centers, where technology may maybe is not as prevalent or is not as, widely used as it is. And, you know, certain practices in larger health systems, and I would imagine among behavioral health providers, maybe that's you know, even more of a challenge.

So as we look toward data being a solution, you know, did you what was your observation in terms of access to technology? Is there is there a gap in these kind of siloed behavioral health, physical health worlds, or are we making progress there?

Alyssa Lord
In many ways, the behavioral health community has continued to play catch up because they were not included in the high tech initially. So when there were incentives for the health care system to integrate electronic health records into their broader networks, that was not necessarily offered to behavioral health providers. I think we've seen some great strides. I know the District of Columbia, for example, a couple of years ago had created a program, that was a multi-tiered multi-phased program that dependent upon where the behavioral health provider was in their onboarding of an ear.

There was funding that was made available. So it was you don't have any EHR. So here's funding for an H.R. You want to add a module, here's funding to add the module. You want to invest in data and analytics. Here's funding for that. So I do think the behavioral health community was at a significant deciding edge from a technological perspective.

We've seen more movement in some ways. And the somatic side of group practices, or not as many providers just hanging a shingle, where within the behavioral health community, we still have a large number of individual practitioners. And so their ability to afford and EHR and be able to produce data, it looks very, very different.

Jennifer Colamonico
So a lot of what you've talked about as a solution, is really what a lot of people would call value based care. I know you have a lot of experience in this, and I would just like, love to hear a little bit more about, you know, how this really could work in practice, particularly when you have if you have a kind of a carve out state, right.

How do we align these incentives? If really the, the pathway to program integrity is about, you know, alignment on quality and alignment on outcomes. How do we inline incentives and align measurement if we have a system that is fractured or just simply kind of a carve out state? You know, what does good look like there.

Alyssa Lord
Whether it is a carving or carve out? We have seen states be really thoughtful and strategic around how you deploy value based care. And so, you know, there are also models coming out of CMMi that are going, the ahead model, for example, which Maryland is a part of, which includes behavioral health measures that we are going to hold providers accountable for.

And so I don't think I think the limitations are the rules that we impose upon ourselves. Now, obviously there are fiscal constraints. So being mindful of where states are with their budgetary process and their ability to move towards value based care, but it also doesn't just have to be the state, right? I think we've also seen this movement within the payer landscape of where they see value around value based care.

And so we can take a look at and there are core measure sets that have been around for years. But looking at a reduction in behavioral health Ed utilization or behavioral health hospitalizations, you can start to take and tie some of these pieces around managing total cost of care. It does not have to create a robust complexity for providers to be able to access that information.

I'm not saying it's always easy, but I do think there are demonstrated pathways where we have seen this work. I mean, you mentioned FCS, FCS have been in value based agreements for years. CBCs utilizes a prospective payment system and is another example where the behavioral health community has re-envisioned. What does value based care look like? Aligning payment with outcomes and having the ability of, in many instances to have a quality bonus payment.

So we see movement in this direction in the behavioral health space, in the somatic space. And I do think we're starting to see more movement within the more integrated space where I mentioned before, where I still think there's some work to go.

Jennifer Colamonico
So much of value based care innovation kind of started out in the Medicare space. I've long thought that the opportunity in Medicaid, is probably greater for a whole host of reasons. But I'm wondering if you're, you know, how bullish you are on that. You know, in terms of, of transformation, when we look for pathways to value based care, obviously, you know, costs are lower in Medicaid for a lot of reasons.

You know, gaps with providers, oftentimes, networks are challenged. Are those types of incentives, you know, more likely to find success in Medicaid than in Medicare, based on your experience?

Alyssa Lord
I think there's a lot of overlap and lessons that we can learn from Medicare for how we think about advancing value based care in the Medicaid space. I mean, you also have a not an insignificant number of individuals that are duals where they are Medicaid, Medicare. And so what does value based care look like for that community and population?

If we're going to translate what we learned in Medicare. And so I, I don't want us to have a sort of this self-imposed barrier of just because it is Medicare versus Medicare Advantage versus Medicaid, of how we think about advancing care models for individuals.

Jennifer Colamonico
If you could wave a magic wand and redesign how we think about program integrity, what would that future state look like?

Alyssa Lord
Who doesn't love a magic wand? You know, I think in the future, state program integrity would be understood as a shared commitment to using public dollars wisely while strengthening access quality and trust oversight would be based on risk, using data to drive and inform the process, along with being transparent and collaborative providers would receive clear expectations, timely feedback, and practical support.

If we think about other parts of the system in states and plans would focus on enforcement for credible risk and the system would be able to distinguish between fraud, honest error and opportunities for improvement.

Jennifer Colamonico
I appreciate that, and well, thank you for being with us today. We, we're we're thrilled to learn about your journey and, and all of the ways in which, you've impacted the health of Marylanders and, and Marylanders and hopefully, can impact the health of Americans. So we appreciate you.

Alyssa Lord
Thanks for having me.

Jennifer Colamonico
This episode of Vital Viewpoints on Healthcare is sponsored by HMA Information Services. HMAIS is a subscription based service that provides state level data on publicly sponsored programs like Medicaid from the latest managed care enrollment, market share, and financial performance data to up to date RFP calendars and state by state overviews, HMAS has all the information you'll need to power your initiatives to success.

This podcast was produced by myself, Jennifer Colamonico along with Tiffany McKenzie in collaboration with our guests. The content is the property of Health Management Associates.