The NCSL Blog


By Joshua Ewing and Laura Tobler

“Silo” is somewhat of a four letter word in health care these days.

In this case, we are not talking about the grain silo you passed on the way to grandma and grandpa’s house when you were a child. Today, organizational silos refer to groups within a larger system that operate independently and without proper communication, creating inefficiencies and duplication.

Federal and state governments as well as the private market are seeking ways to break down silos that hamper the delivery of high quality, efficient services. Nowhere is this more evident than with the silos between physical health and behavioral health.

The physical health and behavioral health systems operate separately in most places, forcing individuals to make multiple appointments, visit separate facilities, and work with separate institutional bureaucracies to receive care. States must administer two separate systems for rules, regulations and payments—often for the very same Medicaid beneficiaries.  Medicaid patients with chronic conditions who also have a mental illness or substance abuse problem are among the program’s most costly people to serve.

Integrated care has the potential to improve quality, improve patients’ health and contain costs for cash-strapped state governments. A successfully integrated system is one with streamlined regulations that allow for one health team or health entity to treat the "whole person.” It also addresses an issue of importance to states—making Medicaid a more streamlined and efficient program that meets the needs of its beneficiaries.

A new report from the Commonwealth Fund, "State Strategies for Integrating Physical and Behavioral Health Services in a Changing Medicaid Environment," identifies key elements of an integrated health system and examines state strategies to achieve integration.

For example, the authors identify the following strategies for states to consider:

  • Consolidating agencies.
  • Placing state managed care contracting decisions for both physical and behavioral health under the same authority.
  • Providing financial incentives for providers and managed care organizations to integrate care.
  • Increasing data exchange across providers and departments.

Kansas consolidated fiscal and contract management functions during implementation of the state’s new Medicaid managed care program, according to the report. California was one of a few states to take the rare step of consolidating agencies when it eliminated the state's independent mental health and substance use disorder agencies in 2012 and 2013, merging these services within the Medicaid agency. 

Joshua Ewing is a health policy specialist at NCSL. Laura Tobler is a health program director at NCSL.

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About the NCSL Blog

This blog offers updates on the National Conference of State Legislatures' research and training, the latest on federalism and the state legislative institution, and posts about state legislators and legislative staff. The blog is edited by NCSL staff and written primarily by NCSL's experts on public policy and the state legislative institution.