Unlocking Health Savings & Smiles
- psawhney09
- Oct 23, 2023
- 24 min read
Updated: Oct 25, 2023
Unleashing Savings, Outcomes, and Equity with Integrated Healthcare in Value-Based Models
Why Integrating Behavioral Health (BH) into Primary Care is so important?
The value of starting any risk-based contracting efforts with a framework including integrated behavioral health incentives.
TABLE OF CONTENT
Introduction
What is integrated BH & Primary Care?
Integrated behavioral health and primary care is a healthcare approach that combines mental health and primary care services within the same healthcare setting or organization. This integration aims to improve patient outcomes, enhance the quality of care, and reduce healthcare costs by addressing both physical and mental health needs simultaneously. Accountable Care Organizations (ACOs) are a specific healthcare delivery model that focuses on coordinating care for patients and improving healthcare efficiency. Integrating behavioral health into ACOs can offer several advantages.
Why integrating Behavioral Health into Primary Care has never been more important
There is a direct link between behavioral health needs and healthcare utilization. These issues are not just entries in a patient’s medical history; they can affect functional status, quality of life, and productivity. They can contribute to the development of medical conditions as well as the exacerbation of existing conditions. In fact, while roughly one-third of a primary care physician’s panel will have a behavioral health condition that needs addressing, it is not uncommon to see costs for these individuals accounting for almost half of total medical expenses. They typically visit the emergency room more frequently and are more likely to return to the hospital. Their overall costs can be three or four times higher than someone who doesn’t have a behavioral health issue to manage.
Behavioral Health issues are not a new phenomenon but have increased with time and their affect on health outcomes
Nearly 67% of patients with chronic medical disease have comorbid psychiatric illness, yet mental and physical healthcare is frequently siloed in the United States (pre-covid!). Older adults comprise a large proportion of patients with comorbid psychiatric illness.
An estimated 80% of behavioral health conditions are under- or untreated in the current system of care.
In the last two years, side effects of the pandemic such as isolation and delayed care have exacerbated the silent epidemic of behavioral health issues. Adults reporting anxiety and/or depressive disorder are up, and the number of these adults not accessing treatment is also trending in the wrong direction. Deaths due to drug overdose are up dramatically, and suicide rates have increased in almost every state.
ACO National Survey: Access to mental health support in the US today by the YALE SCHOOL OF HEALTH
Out of 862 eligible organizations, 478 ACOs (55%) returned a survey. They omit the 59 ACOs that did not answer at least half of predefined core questions noted (complete rate = 49%22), and the 7 ACOs that did not answer the questions related to services for those with serious mental illness, yielding 412 ACOs for analysis.
In the analysis sample, about half of ACOs were physician-led (52%), 37% of ACOs served states in the South, and 63% served Medicaid expansion states. About one-quarter (28%) included either a CMHC or a behavioral health provider group.
Subsequent data indicates that most ACO respondents reported sharing patient information between behavioral and non-behavioral health clinicians, including behavioral health prescriptions (66.0%), behavioral health diagnoses (67.0%), and physical health treatment (73.9%). Information sharing was more common among large and physician-led ACOs.
Providers had the ability to offer or refer to specialty mental health services in about half of ACOs, with integrated dual disorder treatment most commonly offered (57.1%) and illness management and recovery services least likely to be offered (41.0%).
The most common predictor of offering services, inclusion of CMHCs or behavioral health provider groups as participating ACO providers, was positively associated with four of the five services studied. Although most ACOs (55.3%) reported identifying first episode psychosis patients, only 37.7% reported tracking or referring these patients. No organizational characteristic studied was significantly correlated with the presence of these programs.
Most prior evaluations of alternative payment models and behavioral health characterize the quality of depression treatment. In this study, we consider evidence-based structural outcome measures related to support services recommended by the Substance Abuse and Mental Health Services Administration (SAMHSA) that are likely to benefit patients with serious mental illness. Fewer than half of ACOs reported that providers have the ability to either offer or refer patients to specialty mental health support services. That relatively few providers were able to refer patients to these services is disappointing, although rates may be even lower among non-ACO providers. It may be that nearby behavioral health providers do not offer these services, and ACOs are unlikely or unable to induce centers to offer these programs due to high startup costs and because these programs are likely to help relatively few ACO-attributed patients. One consistent predictor of the outcomes studied is a formal relationship with a behavioral health provider group or CMHC, although only 27.6% of ACOs report such a relationship. One reason for the lack of formal relationships may be the strong incentives faced by capitated providers or commercial insurers to create provider networks limiting those specialties (behavioral health, oncology) likely to attract expensive patients for whom savings may be hard to achieve. Even among ACOs with formal relationships with specialty mental health providers, the ability to refer to the services studied ranges from 51.1% to 72.0%. Limitations of this study include that we do not directly observe services offered by the ACO, response bias may reduce generalizability, survey questions were not formally validated, the availability of a single wave of data, and possible changes in services offered since the data were collected in 2017–2018.
Rising rates of integrated BH condition management in accountable care as leaders realize value
The article explores how Accountable Care Organizations (ACOs) have become leaders in the integration of behavioral health into healthcare delivery. ACOs, originally established under the Affordable Care Act, are evolving to prioritize the seamless coordination of physical and mental health care. The integration of behavioral health into ACOs is driven by a recognition of its significance in improving patient outcomes, reducing costs, enhancing efficiency, and fostering a culture of preventive care. Strategies for integrating behavioral health include co-locating behavioral health professionals with primary care providers, leveraging technology for telehealth and monitoring, partnering with community-based organizations for home-based care, and implementing value-based payment models to incentivize comprehensive care. This approach acknowledges the interconnectedness of physical and behavioral health and aims to provide holistic, patient-centered care within the ACO framework.
Historical Challenges for ACOs & RBEs
Challenges Inherent in Fee-for-Service Economics
Fee-for-service contracting is a prevalent payment model in the United States healthcare system, where providers receive payment for each service they deliver. This payment model presents several challenges for integrated behavioral health care, including:
Financial Disincentives: Under the fee-for-service payment model, providers have a financial incentive to deliver more services, which can lead to overutilization, driving up costs and diminishing the quality of care.
Lack of Reimbursement: Many fee-for-service payers do not adequately reimburse for behavioral health services, making it challenging for integrated care practices to be financially viable.
Administrative Complexity: Billing and coding for behavioral health services can be complex, particularly in a fee-for-service environment, adding to the administrative burden of integrated care practices.
Common Challenges Faced by ACOs Addressing Behavioral Health Concerns:
Shortage of Behavioral Health Workforce: One significant obstacle is the shortage of behavioral health professionals, especially psychiatrists and experts in substance use disorders. This shortage exists both within ACOs and in the broader community, particularly in rural areas. Inadequate reimbursement rates, especially from Medicaid, deter behavioral health professionals from participating. Some licensed providers cannot directly bill Medicare, further limiting access for patients.
Sustainable Funding Model: Developing a sustainable funding model for behavioral health services within a fee-for-service (FFS) reimbursement system is challenging. ACOs often rely on external funding or profits to finance behavioral health services, as billing alone may not cover provider salaries.
Data Sharing Challenges: ACOs face difficulties in sharing data related to mental and substance use disorders due to stringent security requirements for sensitive information. Privacy restrictions hinder the use of electronic health record data for identifying individuals with behavioral health needs and coordinating care between providers.
Resistance to Discussing Mental Health Issues: Both patients and healthcare providers may resist discussing mental health issues due to cultural stigma, reluctance to screen for conditions without clear treatment pathways, and concerns about complicating patients' needs.
In summary, these challenges highlight the complexity of integrating behavioral health into accountable care organizations (ACOs) and the multifaceted barriers they must navigate to effectively address the mental health needs of their patient populations.
Importance & Benefits of Integration
Evidence lately shows how certain ACOs are leading the way and reaping the value
Historically, behavioral health has been separate from mainstream medicine, resulting in fragmented care. This fragmentation leads to inefficiencies, higher costs, and poorer patient outcomes. Recognizing this gap, the Centers for Medicare & Medicaid Services (CMS) began promoting the Integrated Care Model in 2012, acknowledging the interconnectedness of mental and physical health.
The accountable care organization (ACO) model holds the promise of reducing costs and improving care quality by realigning payment incentives to focus on health outcomes rather than service volume.
Rising rates of integrated BH condition management in accountable care as leaders realize value
Comprehensive Care for Better Health Outcomes: Behavioral health plays a pivotal role in an individual's overall well-being. Behavioral health issues often intertwine with physical health conditions. By addressing both dimensions, ACOs can effectively manage chronic diseases and prevent their onset. Many physical health conditions, like diabetes or heart disease, have behavioral components or comorbidities. Addressing behavioral health can optimize care management and even prevent such conditions.
Enhanced Efficiency, Lower Costs: While prioritizing patient well-being, it is vital to consider the financial aspects. Integrating behavioral health can yield substantial cost savings for several reasons. Treating behavioral health disorders early can avert costly interventions later. Simultaneously addressing behavioral and physical health issues reduces hospital readmissions, emergency department visits, and other high-cost care scenarios. Early intervention for behavioral health disorders prevents costly treatments later. Additionally, simultaneous attention to physical and behavioral health reduces expensive hospital readmissions and emergency department visits.
Improved Consumer Satisfaction: Navigating the complex healthcare landscape can be challenging for individuals. ACOs streamline this process by integrating both physical and mental health services under one roof, resulting in heightened satisfaction and improved care access. ACOs strive to provide a seamless patient experience, addressing both physical and mental health needs within a single healthcare system. This leads to increased patient satisfaction and improved care access.
Cultivating a Culture of Preventive Care: Behavioral health focus fosters a culture of preventive care. Addressing lifestyle choices, stressors, and mental health can prevent the onset of various physical health ailments. An integrated approach guides patients towards healthier lifestyles and proactive health management, leading to superior health outcomes and cost savings. Focusing on behavioral health encourages patients to make healthier lifestyle choices and actively manage their health, resulting in improved outcomes and cost savings.
Recognizing the Interconnectedness of Health: The integration of behavioral health into ACOs is not merely a strategic choice; it's an informed approach that acknowledges the intricate interplay between physical and behavioral health. Neglecting one aspect of care can have adverse effects on the other.
In summary, integrating behavioral health into ACOs represents a pivotal step towards achieving comprehensive, value-based care. This approach acknowledges the intrinsic connection between physical and behavioral health, resulting in improved patient care, financial savings, and overall healthcare outcomes.
Strategies for Integrating Behavioral Health to Drive Value in Risk Arrangements
Starting a behavioral health integration (BHI) in your practice can be complex but beneficial to your practice and your patients.
As the healthcare landscape continues to evolve with a greater focus on whole-person care, Accountable Care Organizations (ACOs) are adopting innovative approaches to integrate behavioral health services into their care delivery models. This integration not only enhances the quality of care but also ensures a holistic approach to health where physical, mental, and social needs are addressed in tandem.
One of the most common and effective ways ACOs are integrating behavioral health is through the co-location of services. This involves bringing behavioral health professionals like psychiatrists, psychologists, counselors, and social workers into the same physical facility as primary care providers.
Traditionally, mental healthcare has been siloed and separated from physical health. Having both services under one roof breaks down those divides. Co-location simplifies and expedites the referral process so primary care doctors can easily direct patients to behavioral specialists down the hall or upstairs in the same building. It also fosters seamless communication, collaboration, and care coordination between professionals on a patient's integrated care team. Most importantly, co-locating demystifies and reduces barriers for those who may feel stigmatized about seeking standalone mental health treatment outside their usual source of care. The proximity and normalization of behavioral services make individuals more inclined to access them.
ACOs are also strategically mandating regular behavioral health screenings during annual wellness visits, preventive care appointments, and chronic condition management. By identifying symptoms earlier through evidence-based screening tools, providers can direct at-risk patients to integrated behavioral health resources sooner for early intervention. For example, a primary care doctor may administer a PHQ-9 depression screening questionnaire that indicates moderate symptoms of depression. They can immediately refer that patient to an in-house psychologist for therapy and prescribe anti-depressants rather than telling them to independently find a behavioral specialist elsewhere. Early detection paired with warm hand-offs facilitates entry into treatment.
Additionally, ACOs are increasingly leveraging technology to enable integrated behavioral health. Health systems are partnering with digital health companies that provide registries, caseload management tools, and telemedicine platforms to seamlessly connect patients to behavioral care.
For instance, Atlantic Health System which operates in New Jersey, Pennsylvania, and New York collaborated with NeuroFlow. They now use NeuroFlow's suite of tools so providers can identify patients in need of services through screening programs, track their progress through treatment plans, and pinpoint individuals requiring outreach based on risk algorithms. Atlantic Health patients also use NeuroFlow's educational resources for self-management and virtually access therapists and psychiatrists. This technology removes geography as a barrier and expands access to integrated behavioral care.
ACOs are also turning to home and community-based approaches for delivering integrated care through partnerships with external organizations. The medical and social complexities of serious mental illness make it difficult for these patients to access clinic-based services. Solutions like the Massachusetts-based Innovative Care Model allow ACOs to coordinate in-home behavioral health and physical care to high-need populations with SMI. Trained community care workers provide psychotherapy but also physical health interventions like medications, vital checks, and chronic care management alongside nursing support – all where the patient is most comfortable. ACOs contracting these mobile integrated services reduce healthcare utilization and costs for vulnerable subsets likely to have co-occurring conditions.
Partnerships with community mental health centers, addiction treatment centers, crisis stabilization units, and recovery organizations provide continuity of care for patients once discharged. ACOs are building networks of support spanning inpatient psych units, partial hospital programs, and intensive outpatient centers to manage transitions and improve outcomes. Clear attribution and data sharing agreements allow bidirectional communication and limit patients falling through the cracks.
Lastly, ACOs are leveraging value-based payment models to incentivize behavioral health integration. The financial upside of population health drives ACOs to look at the whole person. Bundled payments and shared savings arrangements for chronic physical illnesses now include provisions for comorbid mental health conditions. Providers are rewarded for quality benchmarks tied to depression remission, substance abuse treatment engagement, and limiting psychiatric inpatient readmissions. ACOs are moving towards full-risk capitation using global budgets that enable flexibility in care decisions for body and mind.
Participating in these arrangements incentivizes & funds two additional levers to value creation and incremental shared savings:
Increased Access To Social Workers
In contrast to using licensed clinical social workers as providers collocated with primary care teams, many ACOs hired social workers to support their medical care coordination teams or to serve as independent centralized resources for both short-term behavioral health care and long-term coordination of referrals for mental health treatment. Medical care coordination teams often included pharmacists, licensed clinical social workers (or, less frequently, other social workers), and community resource specialists in addition to nurse care coordinators. The coordinators referred patients with significant mental health issues to social workers for assistance in resolving psychosocial issues, providing short-term behavioral health services, or coordinating long-term mental health treatment.
In other ACOs, social workers played a key role in assisting with behavioral health care needs without being explicitly included in the care management team. One ACO had initially placed a social worker in one of its primary care clinics, but demand was so high that it centralized the social worker so that he or she was available to other primary care clinics. Other ACOs had centralized social work teams. One ACO used social workers to follow up with patients identified through depression screening.
2. Referral Networks
Multiple ACOs adjusted their referral networks to better serve beneficiaries with behavioral health needs by improving connections to community resources, partnering with a behavioral health facility to improve access to care, and reorganizing internal behavioral health resources to improve access to and coordination with primary care providers. Several ACOs expanded their behavioral health networks as part of their care coordination efforts. Care coordination team members catalogued community resources and reached out to them, often providing a bridge to connect beneficiaries to these resources.
Other ACOs created partnerships with behavioral health organizations that varied from formal contractual relationships to informal understandings. As an official at one Pioneer ACO put it: “We don’t have a robust mental health program, so we have a good referral relationship to a behavioral health center. The behavioral health center outpatient people come to ACO management meetings but are not contractually affiliated [with the ACO].”
One Pioneer ACO leader reported developing a type of concierge model: “The psychiatrist consults [with the primary care provider] and provides a recommendation on medication management, and then the patient goes back to their primary care physician for ongoing management and has orders for interim consults with the psychiatrist as needed.
In summary, ACOs are strategically and systematically embedding behavioral health across settings of care. Co-location, screening procedures, digital tools, community partnerships, and financial incentives work in synergy to normalize mental healthcare as an essential component of overall health. This multifaceted approach to integration is fulfilling the promise of whole-person coordinated care.
ACO REACH CONSIDERATIONS
The pursuit of a 10X better value-based care enablement solution and the rise of primary care physician management platforms
In the previous year, the U.S. Centers for Medicare & Medicaid Services (CMS) introduced a novel initiative named the ACO Realizing Equity, Access, and Community Health (REACH) model. This innovative model places a strong emphasis on achieving equity, enhancing access to care, and fostering better care coordination, particularly in underserved communities.
Many stakeholders view this initiative as a promising avenue for bolstering the integration of behavioral health services. Notably, one company at the forefront of this movement is the hybrid healthcare firm, One Medical. One Medical, which is under the ownership of Amazon, is renowned for providing comprehensive in-person and behavioral healthcare services to its members. A significant milestone in this journey was the acquisition of Medicare-focused Iora Health, a transaction valued at $2.1 billion, which occurred two years ago.
Today, the majority of One Medical's Medicare-related operations, including its participation in the ACO REACH program, fall under its subsidiary, Iora Health. One of the central strategies employed by One Medical to achieve integrated care involves the inclusion of behavioral health specialists and coaches within their staff. This approach ensures that members receive holistic care that addresses both their physical and mental health needs.
It's noteworthy that a substantial portion, approximately 40% to 50%, of Iora's patient base is enrolled in an ACO REACH program. This initiative not only assists the broader organization in identifying gaps in care but also fosters a renewed focus on promoting equity and enhancing access to essential healthcare services.
Andrew Van Ostrand, the head of government affairs at One Medical, expressed the company's commitment to recognizing the intrinsic link between behavioral and mental health and primary care. He highlighted the challenge posed by the traditional fee-for-service model, which often hindered collaborative care approaches.
While the ACO REACH program is still in its early stages, it serves as a compelling demonstration of the potential role of behavioral health in the future of healthcare. Moreover, it offers a viable pathway for addressing pertinent questions related to behavioral health access and equity.
Integrations, Operations & Implementation
Beyond theory: operationalizing and implementing integrated models with an emphasis on the combined medicine-psychiatry service
Integrated behavioral healthcare models, such as medicine-psychiatry services,
are feasible, improve patient outcomes, and reduce costs.
Representative case showing feasibility and proving improved outcomes + financials:
The Duke University Hospital medicine-psychiatry service provides holistic patient care and serves as a model for those interested in developing combined services or training programs elsewhere. Combined residency training in psychiatry is a
way to provide a workforce of physician-scientist educators adept at providing
coordinated, integrated care for complex patients with comorbid illness.
Integrated care models for patients, especially those with comorbid medical and psychiatric illness, a focus on combined medicine-psychiatry inpatient services and training programs are highly effective and directly correlated with SDoH issues.
Key operating functions enabling success in case:
Nearly 50% of patients with chronic medical disease have comorbid psychiatric illness, yet care is often siloed. This leads to fragmented care, higher costs, and poorer outcomes.
Older adults comprise a substantial proportion of patients with medical-psychiatric comorbidity. They frequently have undiagnosed or undertreated mental health needs during hospitalization.
Integrated behavioral health models like collaborative care improve outcomes and reduce costs, but uptake of inpatient models like medicine-psychiatry units has been gradual.
Collaborative Care and Complexity Intervention Units:
Outpatient collaborative care models have demonstrated improved outcomes and reduced costs. Evidence also supports acute inpatient models like complexity intervention units (CIUs).
CIUs originated in European health systems to manage medical-psychiatric complexity. Adoption in the U.S. has been slow but increasing.
Benefits of CIUs include proactive psychiatry input and coordinated care. Considerations include unit location, policies, patient criteria, and impact on referrals and reimbursement.
The Duke Medicine-Psychiatry Service:
Duke's med-psych service, founded in 2001, provides combined inpatient care but differs from a dedicated CIU. It accepts medically complex patients with concomitant psychiatric issues.
The team comprises dual-trained internal medicine-psychiatry (IMP) attendings, psychiatry interns, and IMP residents. Consultants like geriatric psychiatry are available.
Benefits include efficiency, role modeling of integrated care, and appreciation by nurses and trainees. Challenges include education, communication across units, and mission drift.
Training for Collaborative Care:
Combined residencies like IMP provide integrated care training. Trainees gain expertise in managing medical-psychiatric complexity.
Applicants drawn to caring for underserved and complex patients. Graduates predominantly work in integrated care or academic settings.
Duke's IMP residency involves 5 years of rotations meeting both ACGME requirements. The med-psych service provides key training experiences.
Challenges include varied skill trajectories and coordinating schedules. Open communication and commitment to combined training helps residents overcome these.
The Duke med-psych service and IMP residency provide models for developing integrated care and training programs to improve care for comorbid medical-psychiatric illness.
Enablement through advanced technology uses:
Atlantic Health System, a nonprofit healthcare organization, has adopted a proactive, population-health-based approach to care within its Accountable Care Organizations (ACOs). Dr. James Barr, the Vice President of Physician Value-Based Programs and Chief Medical Officer of ACOs at Atlantic Health System, emphasized their commitment to proactive care, with a notable track record of success with Medicare and commercial payers. However, during the COVID-19 pandemic, they encountered challenges with patients facing behavioral health issues that impacted their adherence to medical recommendations and treatment plans.
Dr. Barr explained that these underlying behavioral health conditions led to adverse patient outcomes, including non-compliance with medical advice, medication regimens, and screening appointments. Consequently, this non-compliance often resulted in increased emergency room visits, further straining the healthcare system's resources.
Atlantic Health System operates across New Jersey, Pennsylvania, and New York, encompassing over 400 care facilities and boasting a workforce of 19,000 team members and 4,800 affiliated physicians. Recognizing the significant influence of behavioral health on patient outcomes, the organization sought to enhance their approach by leveraging technology and data-driven solutions.
To address this challenge and expand access to care, Atlantic Health System partnered with Neuroflow, a digital health company. Together, they implemented a collaborative care model to integrate behavioral health services into Atlantic's 16 ACO sites. This innovative partnership empowers clinicians with NeuroFlow's registry and caseload management tools to monitor and evaluate patients' progress. Additionally, AI-powered screening tools identify patients who may require behavioral health services.
Patients in need of these services can access personalized coaching, educational resources, care plans, and motivational tools through the technology platform. Moreover, patients can engage with virtual behavioral health providers if they require therapist consultations. This initiative was initially rolled out to approximately 25,000 patients in the spring, with plans to expand to 50,000 patients in the third and fourth quarters of the year.
Importantly, this collaboration between Atlantic Health System and Neuroflow showcases the potential benefits of a collaborative care model and technology-driven innovations not only for ACOs but also for broader healthcare systems. Dr. Tom Zaubler, Chief Medical Officer of Neuroflow, highlighted that ACOs can serve as incubators for innovative healthcare technologies and models of care. Health systems can observe the success of these models within ACOs and subsequently adopt them, recognizing their immense potential.
In summary, this partnership demonstrates how ACOs can leverage external collaborations and technology solutions to enhance their services, even without in-house co-locations. It serves as a testament to the role ACOs can play in driving the adoption of innovative healthcare technologies and care models across the broader healthcare landscape.
Overcoming inherent barriers for Rural Populations
Rural areas, arguably, exhibit a greater need for integrated behavioral health (BH) services compared to more densely populated regions, primarily due to the strong correlation between rural patients and equity-related challenges
The integration of primary care and behavioral health treatment has been shown to enhance outcomes and improve access to care. However, this integration faces significant hurdles, particularly in rural settings. Rural Americans experience higher rates of mental illness and substance use disorders, yet they have limited access to specialized services. As a result, they heavily rely on primary care providers for their behavioral health needs.
In this context, rural health centers such as Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) play a pivotal role in expanding access to integrated care. However, it's crucial to acknowledge that many rural healthcare facilities are currently at risk of closure, underscoring the urgency of addressing these challenges.
To address the unique needs of rural populations and improve access to integrated care, the following policy recommendations have been proposed:
The Department of Health and Human Services (HHS) should identify standardized quality metrics tailored to integrated care, facilitating benchmarking and accountability.
HHS should establish core service elements that define behavioral health integration within primary care settings, ensuring consistency across providers.
The Centers for Medicare & Medicaid Services (CMS) should guarantee the availability of sufficient provider networks and access to behavioral health specialists for Medicaid, CHIP, and Medicare Advantage beneficiaries. This includes the promotion of virtual care providers.
Support for Workforce and Providers in Rural Areas:
Expand Medicare's physician bonus program, currently focused on Mental Health Health Professional Shortage Areas (HPSAs), to encompass other types of behavioral health providers, incentivizing them to practice in rural areas.
Introduce a federal tax credit aimed at healthcare providers practicing in rural shortage areas, thereby improving provider retention.Make the Teaching Health Center Graduate Medical Education program a permanent fixture to ensure the continuity of residency training in rural clinics.
Increase funding from the Health Resources and Services Administration (HRSA) for rural residency rotations at traditional hospitals, offering more residents exposure to rural practice.
Promote training in buprenorphine prescribing for Opioid Use Disorder (OUD) through medical schools and Continuing Medical Education (CME) programs, with the support of the Substance Abuse and Mental Health Services Administration (SAMHSA) and HRSA.
Provide technical assistance to states through the Center for Medicaid and CHIP Services (CMCS) on policies related to Medicaid coverage of interprofessional consultations and counselors.
Payment and Delivery System Reforms:
Remove the cap that currently limits RHCs to providing a maximum of half their services for behavioral health, enabling them to offer more comprehensive care.
Clarify Medicare exceptions to same-day billing restrictions to encompass not only mental health but also substance use treatment.
Increase reimbursement for the Collaborative Care Model while reducing cost-sharing to encourage its broader adoption.
Make permanent the telehealth flexibilities for rural residents, allowing for audio-only services within established patient-provider relationships.
Support for Key Rural Populations:
Expand the Veterans Affairs' Solid Start program to aid service members with behavioral health conditions in transitioning to civilian life.
HHS should instruct its agencies to leverage grants aimed at addressing provider shortages and expanding the healthcare workforce within tribal communities.
SAMHSA and CMS should promote integration within specialty behavioral health clinics through grants, while also clarifying that Opioid Treatment Programs (OTPs) can bill Medicare for primary care services.
These recommendations outline a comprehensive approach to expanding integrated primary care and behavioral health services in rural America, thereby enabling more providers to deliver essential care to underserved populations.
Estimated Clinical Outcomes and Cost Effectiveness + Savings associated with provisioning
Studies are now openly being published on both the qualitative and quantitative impact of this model of care in VBC arrangements; especially in Medicaid and DSNP members
CASE 1: Estimated Clinical Outcomes and Cost-effectiveness Associated With Provision of Addiction Treatment in US Primary Care Clinics
JAMA Network Open. 2023;6(4):e237888.
Corrected on May 11, 2023. doi:10.1001/jamanetworkopen.2023.7888
IMPORTANCE US primary care practitioners (PCPs) are the largest clinical workforce, but few provide addiction care. Primary care is a practical place to expand addiction services, including buprenorphine and harm reduction kits, yet the clinical outcomes and health care sector costs are unknown.
OBJECTIVE To estimate the long-term clinical outcomes, costs, and cost-effectiveness of integrated buprenorphine and harm reduction kits in primary care for people who inject opioids.
DESIGN, SETTING, AND PARTICIPANTS In this modeling study, the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection related infections, overdose, hospitalization, and death, was used to examine the following treatment strategies:
(1) PCP services with external referral to addiction care (status quo),
(2) PCP services plus onsite buprenorphine prescribing with referral to offsite harm reduction kits (BUP), and
(3) PCP services plus onsite buprenorphine prescribing and harm reduction kits (BUP plus HR).
Model inputs were derived from clinical trials and observational cohorts, and costs were discounted annually at 3%. The cost-effectiveness was evaluated over a lifetime from the modified health care sector perspective, and sensitivity analyses were performed to address uncertainty. Model simulation began January 1, 2021, and ran for the entire lifetime of the cohort.
MAIN OUTCOMES AND MEASURES Life-years (LYs), hospitalizations, mortality from sequelae (overdose, severe skin and soft tissue infections, and endocarditis), costs, and incremental cost effectiveness
ratios (ICERs).
RESULTS The simulated cohort included 2.25 million people and reflected the age and gender of US persons who inject opioids. Status quo resulted in 6.56 discounted LYs at a discounted cost of $203 500 per person (95%credible interval, $203 000-$222 000). Each strategy extended discounted life expectancy: BUP by 0.16 years and BUP plus HR by 0.17 years. Compared with status quo, BUP plus HR reduced sequelae-related mortality by 33%. The mean discounted lifetime cost per person of BUP and BUP plus HR were more than that of the status quo strategy. The dominating strategy was BUP plus HR. Compared with status quo, BUP plus HR was cost-effective (ICER, $34 400 per LY). During a 5-year time horizon, BUP plus HR cost an individual PCP practice approximately $13 000.
CONCLUSIONS AND RELEVANCE This modeling study of integrated addiction service in primary care found improved clinical outcomes and modestly increased costs. The integration of addiction service into primary care practices should be a health care system priority.
CASE 2: Medicaid Value-Based Payments and Health Care Use for Patients With Mental Illness
JAMA Health Forum. 2023;4(9):e233197.
doi:10.1001/jamahealthforum.2023.3197.
Ashley Lewis, BS; Renata E. Howland, PhD;
Leora I. Horwitz, MD; Sunita M. Desai, PhD
IMPORTANCE Medicaid patients with mental illness comprise one of the most high-need and complex patient populations. Value-based reforms aim to improve care, but their efficacy in the Medicaid program is unclear.
OBJECTIVE To investigate if New York state’s Medicaid value-based payment reform was associated with improved utilization patterns for patients with mental illness.
DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used a difference-indifferences analysis to compare changes in utilization between Medicaid beneficiaries whose outpatient practices participated in value-based payment reform and beneficiaries whose practices did not participate from before (July 1, 2013-June 30, 2015) to after reform (July 1, 2015-June 30, 2019). Participants were Medicaid beneficiaries in New York state aged 18 to 64 years with major depression disorder, bipolar disorder, and/or schizophrenia. Data analysis was performed from April 2021 to July 2023.
EXPOSURE Beneficiaries were exposed to value-based payment reforms if their attributed outpatient practice participated in value-based payment reform at baseline (July 1, 2015).
MAIN OUTCOMES AND MEASURES Primary outcomes were the number of outpatient primary care visits and the number of behavioral health visits per year. Secondary outcomes were the number of mental health emergency department visits and hospitalizations per year.
RESULTS The analytic population comprised 306 290 individuals with depression (67.4%female; mean [SD] age, 38.6 [11.9] years), 85 105 patients with bipolar disorder (59.6%female; mean [SD] age, 38.0 [11.6] years), and 71 299 patients with schizophrenia (45.1% female; mean [SD] age, 40.3 [12.2] years). After adjustment, analyses estimated a statistically significant, positive association between value-based payments and behavioral health visits for patients with depression (0.91 visits; 95%CI, 0.51-1.30) and bipolar disorder (1.01 visits; 95%CI, 0.22-1.79). There was no statistically significant changes to primary care visits for patients with depression and bipolar disorder, but value based payments were associated with reductions in primary care visits for patients with Schizophrenia (−1.31 visits; 95%CI, −2.51 to −0.12). In every diagnostic population, value-based payment was associated with significant reductions in mental health emergency department visits (population with depression: −0.01 visits [95%CI, −0.02 to −0.002]; population with bipolar disorder: −0.02 visits [95%CI, −0.05 to −0.001]; population with schizophrenia: −0.04 visits [95%CI, −0.07 to −0.01]).
CONCLUSIONS AND RELEVANCE In this cohort study, Medicaid value-based payment reform was statistically significantly associated with an increase in behavioral health visits and a reduction in mental health emergency department visits for patients with mental illness. Medicaid value-based payment may be effective at altering health care utilization in patients with mental illness.
Key takeaway & concluding discussion
Populations with high behavioral health needs, complexity of illness, acute care use, health disparities, barriers to specialty care, social risk factors, member interest, alignment with organizational goals, data capabilities, and leadership commitment are primed for high value under value-based integrated care contracts
Representatives from Medicare Accountable Care Organizations (ACOs) have acknowledged the pivotal role of behavioral health conditions in contributing to the high costs incurred by some beneficiaries. Most of the interviewed representatives indicated that their ACOs had instituted changes to enhance the provision of behavioral health care. The two most prevalent approaches involved integrating behavioral health care providers, often licensed clinical or bachelor's-level social workers, into primary care settings and deploying social workers within medical care coordination teams. These social workers offered time-limited support and assistance and facilitated referrals when necessary.
ACOs typically adopted multiple approaches to address behavioral health needs, with the extent of integration varying across their sites. Integrated care was typically provided on a selective basis, targeting specific patients, such as those with particular physical health conditions and depression, or specific locations, often larger sites or those catering to beneficiaries with complex needs. Concurrently, ACOs supported other providers through enhanced clinical pathways and engagement of social workers within care coordination teams. These social workers helped individuals requiring ongoing or long-term care by establishing improved referral networks, ensuring that ACOs catered to both patients treatable within primary care clinics and those requiring more specialized care beyond such settings.
Many of the behavioral health programs developed and implemented were either preexisting or aligned with concurrent organizational initiatives that complemented ACO efforts. Several ACOs had expanded existing programs or were undergoing significant changes in their delivery systems, such as transitioning to patient-centered medical homes, which facilitated enhanced care coordination. These programs were continuously evolving.
Funding for many of these models, particularly integrated care models, relied on grants and discretionary organizational funds, which were not readily available in all organizational structures, especially Advance Payment ACOs. This underscores a key challenge in bridging the gap between fee-for-service (FFS) and population-based payment approaches. The ACO payment model represents a hybrid of these systems, and uncertainties about receiving shared savings posed sustainability challenges. In addition to the ACO payment approach, various initiatives explored avenues for sustained funding for integrated care models, including bundled payments.
Many ACOs did not prioritize behavioral health or felt overwhelmed and uncertain about improving behavioral health services. The challenges related to accessing behavioral health providers and integrating them into primary care settings were deeply rooted in the historical fragmentation of care and would require time to resolve. The limited efforts made by only a few ACOs to enhance care for individuals with substance use disorders suggested that addressing the complexities of this population's treatment was even more intricate than improving care for those with mental health disorders.
However, there is a growing interest among ACOs in better coordinating and integrating behavioral health with primary care. Representatives from well-established ACOs noted a shifting organizational focus, seeking to recapture experiences from a time when behavioral health was more seamlessly integrated into primary care, as current fee-for-service systems restrict. Although recovering past resources and knowledge may prove challenging, interviewees conveyed a clear sense that as payment models from public and private payers transition away from fee-for-service toward capitated payments, the integration of behavioral health care services will regain prominence.
ACOs are increasingly recognizing the significance of addressing behavioral health care needs to manage utilization and spending. However, their success in integrating and coordinating behavioral health with primary care has been mixed. While some organizations have co-located behavioral health providers and improved coordination, others have established mechanisms for short-term behavioral health support and strengthened their referral networks for long-term treatment. Significant challenges remain, including issues related to provider access, sustainable financing, data sharing, and resistance to treatment, both among providers and patients. Nevertheless, the ongoing shift toward capitated payments is ushering in a new era of coordination and integration between physical and behavioral health, expanding effective healthcare models to address all health needs.
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