Editor’s note: This post is part of a periodic Health Affairs Blog series, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation. The authors of this post are part of the team evaluating the Oregon model.
Primary care practices in Oregon and elsewhere have been moving toward the Patient Centered Primary Care Home (PCPCH) model. As they emphasize whole-person primary care that is accessible, high in quality, and safe, Oregon’s Alternative Payment Methodology (APM) pilot is an important step to align payment with these core principles. The APM pilot has been described as a bridge to value-based care. It isn’t the solution to the fee-for-service treadmill, but some think it’s a step in the right direction.
The APM pilot is testing the idea that a per-member-per-month (PMPM) fee to care for a population can support comprehensive care. Integration of physical and behavioral health care is a great case for examining alternative payment methodologies, and it gives us a peek into what Oregon’s APM is (and isn’t) achieving.
Integration of behavioral health and primary care by health care systems is one of the most robust examples of patient-centered, comprehensive care that I have observed in this model. We know that emotional and behavioral issues commonly compound physical health risks and lead to worsening health outcomes. We also know that primary care is where most people struggling with these commonly co-occurring conditions are seen by health care professionals.
Our research team at Oregon Health & Science University have had the incredible opportunity to observe 25 practices across the nation, including six in Oregon that are working to deliver integrated, whole-person primary care. Integrated care is a practicing team of primary care and behavioral health clinicians, working together with patients and families, to address the spectrum of behavioral health concerns that present in primary care, including mental health disorders as well as psychosocial factors associated with physical health, at-risk behaviors, or health behavior change (e.g., smoking, diet). In some cases, a case management team also facilitates enabling services (such as transportation to appointments) or connects patients with community resources.
We have visited these practices through our work on three studies:
- Advancing Care Together, a demonstration project in Colorado supported by The Colorado Health Foundation to advance integration in 11 practices;
- a workforce competencies assessment supported by the Agency for Healthcare Research and Quality, CalMHSA, and Maine Health Access Foundation to study integrated care workforce in practices across the U.S.; and
- TEAM-UP, a study funded by the National Institute of Mental Health to identify the health IT needs of integrated teams. Two practices participating in TEAM-UP are also participating in APM.
Through this work, we have learned that the transition to practice that delivers integrated care is an enormous undertaking. It involves structural, process, and cultural changes that are not for the faint of heart.
For some practices in Oregon, the APM pilot is allowing experimentation with embedding behavioral health professionals on their teams. In many of these clinics, physicians can now immediately refer patients to these behavioral health clinicians in a “warm handoff,” meaning the physician introduces the patient to the specialist in the clinic at the end of the visit.
Let’s look at an example. The primary care clinician determines that her patient is suffering from depression and this is impacting how the patient manages his diabetes. The clinician suggests that the patient meet another member of her team. The clinician invites the behavioral health clinician to join the visit, and the primary care clinician explains, with the patient’s help, what the patient is experiencing. The primary care clinician leaves the examination room, and the behavioral health clinician and patient begin addressing the patient’s depression right away. These introductions can help reduce the stigma of receiving mental health care and ensure access to the appropriate behavioral health care provider.
Warm handoffs don’t routinely happen in the typical primary care practice for a number of reasons. First, many primary practices cannot afford to employ a behavioral health clinician. Second, in those practices that do employ a behavioral health clinician, primary care clinicians often cannot find the behavioral health clinician because s/he is located on another floor or part of the building. This is a huge barrier, and renovating space to support integrated care costs money.
Third, behavioral health clinicians may be busy, particularly if a practice is employing a traditional model of 50-minute behavioral health therapy sessions for referred patients. In the traditional model, behavioral health clinicians focus on patients who need long-term therapy, who go through a formal intake. The clinician is paid for services rendered. If successful, a behavioral therapist will have a full schedule, making it prohibitively expensive to hire enough traditional behavioral health professionals to meet a clinic’s patient demand. This model leaves no room on their schedule for warm handoffs, particularly if these handoffs are not reimbursed. The result is that these professionals are inaccessible to the primary care team and their patients.
One of the clinics in the APM Pilot estimated that nearly half of the patients in its population has either depression or some other health issue with a behavioral health-related diagnosis. For many patients, long-term therapy and a 50-minute visit is not needed to help with their mild to moderate emotional or behavioral problem. In these cases, behavioral health clinicians can offer brief, problem-focused therapy. In this model, the behavioral health clinicians become familiar with the clinic’s panel of patients, and the team moves to a truly population-based approach. As of yet, however, this level of integration still remains the promise of a new care model rather than the current reality.
The Role of Payment Reform
All of the practices we have visited are early adopters, and while money is not the motivating factor for these practices (how could it be?), financing must be addressed to sustain integration efforts. If the primary way a health provider is paid is through physician visits (which is how providers were paid under the Fee-for-Service model), then it’s extremely hard to finance an integrated health care model. The APM pilot is one step toward a payment system that better enables health systems to implement integrated care in a financially viable way.
While APM is not specifically funding primary care-behavioral health integration, it is freeing up practices to look more broadly at how they treat their patients.The practices in the APM pilot do not have requirements for how to they spend their PMPM fee. Therefore, instead of needing to generate a high number of physician-patient primary care visits, they now have the flexibility to spend some of their fees on behavioral and mental health services. As long as the net effect is budget-neutral, they can treat patients in new ways and with new combinations of providers.
Integrated care is comprehensive primary care. To make it common practice will require leadership to push further on paying for services that are central to comprehensive primary care, align payment across payers to reduce complexity, and support system-wide practice change.