Scattergood Foundation

Advancing Innovative Strategies for Change in Behavioral Health

Brattleboro Retreat

Name of Innovative Program: 
Management Service Organization-Vermont Care Collaborative
Sponsoring Organization
Brattleboro Retreat
Name of Innovative Program Lead: 
Dr. Robert Simpson
E-mail Address of Innovative Program Lead:
Project Description: 
   The Brattleboro Retreat and Blue Cross, two of Vermont’s leading not-for profit health care organizations,  have developed an innovative partnership that integrates the management for medical, mental health and addiction care though a new, jointly owned and operated Managed Service Organization, Vermont Collaborative Care (VCC). This new entity is consistent with the larger Vermont health care reform vision that is intended to both improve health outcomes and reduce costs. The integration of physical, mental health and addiction care is expected to improve results and reduce administrative complexity. Its primary goals include: 
  • Local ownership assuring that decisions are made with an understanding of local culture
  • Alignment of clinical goals and financial incentives to encourage best practices and improvement in care
  • A commitment to align its work with Vermont’s broader health care reform efforts
  • Improving member’s experience of care by assuring better coordination among practitioners and by reducing administrative barriers to care
Creativity and Innovation: 
Vermont was one of the first states in the nation to pass parity legislation that recognized the importance of paying for mental health and addiction disorders in the same manner accorded to medical illness. Vermont mandated that health plans operating in the state offer the same benefits design and financial support to those living with a mental illness as it did to those living with a medical illness.  However this notion of parity has been limited to benefit design while there remained a split (carve out) in the manner in which mental health and medical health have been managed. For the first time in Vermont, medical, mental health and addiction care will be coordinated under one organization guaranteeing the concept of person centered care. This integrated model of care recognizes that people often experience multiple problems that compound the need for better communication and coordination between practitioners and members.
Due to silo funding streams the best that Vermont has been able to accomplish in terms of integrated care is a series of pilot projects that have not been done on a large scale to develop significant outcomes. VCC will have a membership of nearly 1/3 of Vermont’s population and will involve the Blue Cross which covers 70% of all private coverage. With a membership this large the opportunity for affecting real change increases. Providers who previously had multiple plans and demands to respond to will now practically have only two entities with whom to deal, the state Medicaid program and VCC. VCC can take existing pilots projects that have shown promise and expand on them and create new projects that have been on the drawing board and move them towards implementation. VCC can then partner with state efforts further breaking down silos of clinical approaches to services.     
Clinical literature demonstrates that the impact of untreated mental health issues on medical outcomes and cost is high, not to mention the lesser quality of life of the people impacted with untreated or undertreated illnesses. VCC’s model of integrating medical and mental health care management is intended to have an impact on the ‘total cost of care’. Rather than carving out certain categories of care or certain risk pools, the VCC model will demonstrate that by identifying high risk members and high volume providers a more targeted and informed approach to managing risk can be obtained. By stratifying pockets of members based on need, resources can be utilized to assure coordination of services for the top 5-10% of members with multiple complex issues who consume up to 70-80% of resources. Education and early intervention for members with higher risk will be supported with wellness and prevention services.
The outline of VCC is easily duplicated as its primary values are straight forward:
  • Create a management system that recognizes the importance of treating the whole person
  • Develop an infrastructure to support the notion of parity from both a clinical as well as a business perspective
  • Bring mental health practitioners together with medical practitioners and provide both with the right supports, a system that rewards outcomes not volume, that rewards coordination, reduces duplication, allows practitioners to mentor each other
  • Listen to consumers and recognize that they are still the best source of their own recovery
  • Develop an integrated treatment plan that is owned by the member and stays with him/her regardless of where treatment is being provided. This will assure that communication and expectations are clear
  • Move from a fee for service process that rewards volume, to a payment stream that follows the member, expects coordination and pays for outcomes
Health is influenced by factors in five domains: health care accounts for 10% of the outcome, behavioral patterns 40%, genetic predisposition 30%, social circumstances 15%, and environmental exposures 5%. By focusing on integrated mental and physical health, the literature is clear that resolving these psychiatric disorders in the general medical setting will drive down the demand for general medical health care, promote more efficient use of care by both patients and their families and preserve scarce medical resources that can be deployed more wisely elsewhere.VCC will reward outcomes that produce healthy members not excessive volumes produced on a fee for service basis by providers. Outcomes based upon medical management guidelines that target the integration of mental and physical health and focus on the reduction in the total cost of care of medium and high risk patients with complex mental and physical illnesses will be developed and strategies implemented.